Healthcare Provider Details

I. General information

NPI: 1558746271
Provider Name (Legal Business Name): BUNTROCK DETNAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 2ND AVE W SUITE 102
WILLISTON ND
58801-3485
US

IV. Provider business mailing address

2204 2ND AVE W SUITE 102
WILLISTON ND
58801-3485
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-3333
  • Fax: 701-572-1039
Mailing address:
  • Phone: 701-774-3333
  • Fax: 701-572-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1726
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1543
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2170
License Number StateAZ

VIII. Authorized Official

Name: DANELLE ESTRADA
Title or Position: PRACTICE COORDINATOR
Credential:
Phone: 701-774-3333