Provider Demographics
NPI:1023372265
Name:BUNTROCK, BENJAMIN R (DMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:BUNTROCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2723
Mailing Address - Country:US
Mailing Address - Phone:218-846-1900
Mailing Address - Fax:
Practice Address - Street 1:1106 W RIVER RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2723
Practice Address - Country:US
Practice Address - Phone:218-846-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13140122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist