Provider Demographics
NPI:1598887085
Name:BRUNER, PHILLIP B (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:B
Last Name:BRUNER
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 1:400 SARALAND BLVD N
Mailing Address - Street 2:SUITE A
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-2152
Mailing Address - Country:US
Mailing Address - Phone:251-675-5861
Mailing Address - Fax:251-675-5105
Practice Address - Street 1:400 SARALAND BLVD N
Practice Address - Street 2:SUITE A
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-2152
Practice Address - Country:US
Practice Address - Phone:251-675-5861
Practice Address - Fax:251-675-5105
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3573CS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL591870OtherUNITED CONCORDIA INSURANC
AL510 90863OtherBLUE CROSS BLUE SHIELD OF