Healthcare Provider Details

I. General information

NPI: 1013994292
Provider Name (Legal Business Name): MATTHEW KAWABORI BRUNER DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE ROAD ATTN: MCDS-NH US ARMY DENTAL ACTIVITY HAWAII
TRIPLER AMC HI
96859-5000
US

IV. Provider business mailing address

1 JARRETT WHITE ROAD ATTN: MCDS-NH US ARMY DENTAL ACTIVITY HAWAII
TRIPLER AMC HI
96859-5000
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-1021
  • Fax: 808-433-3928
Mailing address:
  • Phone: 808-433-1021
  • Fax: 808-433-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2013
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: