Provider Demographics
NPI:1659468247
Name:BRUNK, GARY P (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:P
Last Name:BRUNK
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 1:2345 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805
Mailing Address - Country:US
Mailing Address - Phone:419-227-5544
Mailing Address - Fax:419-227-1520
Practice Address - Street 1:2345 W ELM ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805
Practice Address - Country:US
Practice Address - Phone:419-227-5544
Practice Address - Fax:419-227-1520
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2914270Medicaid