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General NPI Number Information
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NPI Number | 1902116288
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
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Dates
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Enumeration Date | 10/20/2010
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Last Update Date | 10/20/2010
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Provider Practice Location Address
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Address Line | 1200 CREST VIEW DR STE 1
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City | HUDSON
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State | WI
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Zip | 54016-9391
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Country | US
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Telephone | 715-381-7070
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Fax | 715-381-0383
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Provider Business Mailing Address
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Address Line | 1200 CREST VIEW DR STE 1
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City | HUDSON
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State | WI
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Zip | 54016-9391
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Country | US
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Telephone | 715-381-7070
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Fax | 715-381-0383
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD WILLIAM BRUNTON
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Credential | D.D.S.
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Telephone | 651-351-1010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 4482
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License Number State | WI
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