MEDICARE: BENJAMIN R BUNTROCK DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D13140	MN

General Provider Information

NPI Number	:	1023372265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN R BUNTROCK DMD

Provider Business Mailing Address
First Line	:	1106 W RIVER RD
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-2723
Country	:	US
Telephone Number	:	218-846-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1106 W RIVER RD
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-2723
Country	:	US
Telephone Number	:	218-846-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2012
Last Update Date	:	07/03/2012

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