Provider Demographics
NPI:1730197468
Name:CRYSTAL LAKE ORAL MAXILLOFACIAL SURGERY LTD
Entity type:Organization
Organization Name:CRYSTAL LAKE ORAL MAXILLOFACIAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRUKSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-459-5600
Mailing Address - Street 1:690 N IL ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3790
Mailing Address - Country:US
Mailing Address - Phone:815-459-5600
Mailing Address - Fax:815-459-5615
Practice Address - Street 1:690 N IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-3790
Practice Address - Country:US
Practice Address - Phone:815-459-5600
Practice Address - Fax:815-459-5615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190181371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID019025282Medicaid
IL019016621Medicaid
IL019018137Medicaid
IL019013457Medicaid
1700865441OtherNPI # DR. JOHN RICHARD
ID019025282Medicaid
ILT37819Medicare UPIN
ILT35304Medicare UPIN
ILU81648Medicare UPIN
IL761910Medicare ID - Type UnspecifiedDR. KURT BRUKSCH
IL019016621Medicaid
ILT38692Medicare UPIN
IL206350Medicare ID - Type UnspecifiedDR. THOMAS SKIBA