Healthcare Provider Details

I. General information

NPI: 1235128992
Provider Name (Legal Business Name): RICHARD WILLIAM BRUNTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 CURVE CREST BLVD W
STILLWATER MN
55082-4079
US

IV. Provider business mailing address

15270 PAINTERS LANE CIR N
STILLWATER MN
55082-1642
US

V. Phone/Fax

Practice location:
  • Phone: 651-351-1010
  • Fax: 651-351-9333
Mailing address:
  • Phone: 651-436-4145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberMN10762
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4482
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: