Healthcare Provider Details

I. General information

NPI: 1891714135
Provider Name (Legal Business Name): MARK A BRUNNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2064 BALDWIN ST STE A
JENISON MI
49428-8773
US

IV. Provider business mailing address

2064 BALDWIN ST STE A
JENISON MI
49428-8773
US

V. Phone/Fax

Practice location:
  • Phone: 616-264-3815
  • Fax: 404-352-9381
Mailing address:
  • Phone: 404-352-3123
  • Fax: 404-352-9381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12499
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: