Provider Demographics
NPI:1497095608
Name:BRUNK FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:BRUNK FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-283-2929
Mailing Address - Street 1:607 W ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1234
Mailing Address - Country:US
Mailing Address - Phone:618-940-0542
Mailing Address - Fax:
Practice Address - Street 1:805 MARKET ST
Practice Address - Street 2:UNIT B
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1635
Practice Address - Country:US
Practice Address - Phone:618-940-0542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019107122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096681291Medicaid
IL1001332Medicaid