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General NPI Number Information
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NPI Number | 1558746271
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Entity Type | Organization
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Legal Business Name | BUNTROCK DETNAL PC
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Dates
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Enumeration Date | 07/23/2015
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Last Update Date | 07/23/2015
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Provider Practice Location Address
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Address Line | 2204 2ND AVE W SUITE 102
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City | WILLISTON
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State | ND
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Zip | 58801-3485
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Country | US
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Telephone | 701-774-3333
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Fax | 701-572-1039
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Provider Business Mailing Address
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Address Line | 2204 2ND AVE W SUITE 102
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City | WILLISTON
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State | ND
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Zip | 58801-3485
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Country | US
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Telephone | 701-774-3333
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Fax | 701-572-1039
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Authorized Official
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Title or Position | PRACTICE COORDINATOR
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Name | DANELLE ESTRADA
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Credential |
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Telephone | 701-774-3333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1726
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 1543
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License Number State | ND
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2170
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License Number State | AZ
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