Provider Demographics
NPI:1457672958
Name:BRUNNER, DANIEL PAUL (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:PAUL
Last Name:BRUNNER
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 ROSWELL RD
Mailing Address - Street 2:SUITE 27
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8826
Mailing Address - Country:US
Mailing Address - Phone:770-321-0257
Mailing Address - Fax:770-321-0346
Practice Address - Street 1:3535 ROSWELL RD
Practice Address - Street 2:SUITE 27
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8826
Practice Address - Country:US
Practice Address - Phone:770-321-0257
Practice Address - Fax:770-321-0346
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0138591223S0112X
GA053375204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA402170337BMedicaid