=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528150653
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLEN LOUIS BRUENJES D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 01/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 DAIRY ASHFORD ST 104
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-493-4173
-----------------------------------------------------
Fax | 281-493-4388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 DAIRY ASHFORD RD STE 104
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079-5306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-493-4173
-----------------------------------------------------
Fax | 281-493-4388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 10801
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10801
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------