Provider Demographics
NPI:1376586263
Name:BRUST, DANIEL E (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:E
Last Name:BRUST
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 1:402 W COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1211
Mailing Address - Country:US
Mailing Address - Phone:732-370-4204
Mailing Address - Fax:732-370-1614
Practice Address - Street 1:402 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1211
Practice Address - Country:US
Practice Address - Phone:732-370-4204
Practice Address - Fax:732-370-1614
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI162321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice