MEDICARE: DWIGHT G BULLER DDS PA

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	D7528	MN

General Provider Information

NPI Number	:	1477626646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DWIGHT G BULLER DDS PA

Provider Business Mailing Address
First Line	:	101 W BURNSVILLE PARKWAY
Second Line	:	SUITE 222
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-2572
Country	:	US
Telephone Number	:	952-895-6933
Fax Number	:	952-895-6976

Provider Business Practice Location Address
First Line	:	101 W BURNSVILLE PARKWAY
Second Line	:	SUITE 222
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-2572
Country	:	US
Telephone Number	:	952-895-6933
Fax Number	:	952-895-6976

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DWIGHT GRIFFITH BULLER
Credential	:	DDS
Telephone Number	:	952-895-6933

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	08/22/2020

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