Provider Demographics
NPI:1558746271
Name:BUNTROCK DETNAL PC
Entity Type:Organization
Organization Name:BUNTROCK DETNAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTRADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-774-3333
Mailing Address - Street 1:2204 2ND AVE W
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3485
Mailing Address - Country:US
Mailing Address - Phone:701-774-3333
Mailing Address - Fax:701-572-1039
Practice Address - Street 1:2204 2ND AVE W
Practice Address - Street 2:SUITE 102
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3485
Practice Address - Country:US
Practice Address - Phone:701-774-3333
Practice Address - Fax:701-572-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2170122300000X
MN1726122300000X
ND1543124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty