# CRYSTAL LAKE ORAL MAXILLOFACIAL SURGERY LTD

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1730197468
- **Authorized official:** DR. KURT E BRUKSCH D.D.S. (VICE-PRESIDENT)
- **Authorized official phone:** (815) 459-5600

## Contact information

- **Practice address:** 690 N IL ROUTE 31, CRYSTAL LAKE, IL 60012-3790
- **Practice address phone:** (815) 459-5600
- **Practice address fax:** (815) 459-5615
- **Mailing address:** 690 N IL ROUTE 31, CRYSTAL LAKE, IL 60012-3790
- **Mailing address phone:** (815) 459-5600
- **Mailing address fax:** (815) 459-5615

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 019018137 | IL | Yes |

## Other

- **Enumeration date:** 08/05/2006
- **Last updated:** 06/03/2010