Provider Demographics
NPI:1477629053
Name:WALNUT STREET DENTAL ASSOCIATES PLC
Entity Type:Organization
Organization Name:WALNUT STREET DENTAL ASSOCIATES PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-454-5854
Mailing Address - Street 1:120 WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987
Mailing Address - Country:US
Mailing Address - Phone:507-454-5854
Mailing Address - Fax:507-454-7533
Practice Address - Street 1:120 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-454-5854
Practice Address - Fax:507-454-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty