Provider Demographics
NPI:1790843845
Name:BRUHN, MARK ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:BRUHN
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 1:200 S MARR ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4411
Mailing Address - Country:US
Mailing Address - Phone:920-922-9220
Mailing Address - Fax:920-922-9326
Practice Address - Street 1:200 S MARR ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4411
Practice Address - Country:US
Practice Address - Phone:920-922-9220
Practice Address - Fax:920-922-9326
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50020910151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics