Provider Demographics
NPI:1619195310
Name:UNRUH, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:UNRUH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 LINCOLN WAY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 LINCOLN WAY
Practice Address - Street 2:SUITE 107
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2556
Practice Address - Country:US
Practice Address - Phone:208-664-0489
Practice Address - Fax:208-769-7339
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17641223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics