Provider Demographics
NPI:1083789572
Name:RUNDQUIST, BRENT DONALD (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DONALD
Last Name:RUNDQUIST
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 HIGHWAY 169 NORTH
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2413
Mailing Address - Country:US
Mailing Address - Phone:763-559-0859
Mailing Address - Fax:763-559-4356
Practice Address - Street 1:3401 HIGHWAY 169 NORTH
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2413
Practice Address - Country:US
Practice Address - Phone:763-559-0859
Practice Address - Fax:763-559-4356
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND106431223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics