Provider Demographics
NPI:1619327020
Name:BUNDRICK, BRENTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:
Last Name:BUNDRICK
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 1:7204 E MARSHVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-1191
Mailing Address - Country:US
Mailing Address - Phone:704-981-1664
Mailing Address - Fax:
Practice Address - Street 1:7204 E MARSHVILLE BLVD
Practice Address - Street 2:
Practice Address - City:MARSHVILLE
Practice Address - State:NC
Practice Address - Zip Code:28103-1191
Practice Address - Country:US
Practice Address - Phone:704-981-1664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10327122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist