Healthcare Provider Details

I. General information

NPI: 1568843878
Provider Name (Legal Business Name): WHITNEY VIOLET BRUINS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 KUNDERT ST
TURTLE LAKE ND
58575-4205
US

IV. Provider business mailing address

1131 KELLY DR
WASHBURN ND
58577-4111
US

V. Phone/Fax

Practice location:
  • Phone: 701-448-9111
  • Fax: 701-448-9224
Mailing address:
  • Phone: 701-320-4259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2251
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: