MEDICARE: DR. WALLACE EDWARD BRUNSON JR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	NM1827	NM

General Provider Information

NPI Number	:	1093883936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALLACE EDWARD BRUNSON JR. DDS

Provider Business Mailing Address
First Line	:	1314 CHARDONNAY DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-3102
Country	:	US
Telephone Number	:	505-690-9881
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 CHARDONNAY DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-3102
Country	:	US
Telephone Number	:	505-690-9881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	09/04/2015

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