=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477626646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DWIGHT G BULLER DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W BURNSVILLE PARKWAY SUITE 222
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55337-2572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-895-6933
-----------------------------------------------------
Fax | 952-895-6976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 W BURNSVILLE PARKWAY SUITE 222
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55337-2572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-895-6933
-----------------------------------------------------
Fax | 952-895-6976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DWIGHT GRIFFITH BULLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 952-895-6933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D7528
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------