Provider Demographics
NPI:1619010477
Name:BRUGGEMAN, VERN BARRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:VERN
Middle Name:BARRY
Last Name:BRUGGEMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SO WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-524-2036
Mailing Address - Fax:208-523-9004
Practice Address - Street 1:333 SO WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401
Practice Address - Country:US
Practice Address - Phone:208-524-2036
Practice Address - Fax:208-523-9004
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1471122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001596200Medicaid