Provider Demographics
NPI:1851503379
Name:GRUNERT, BRIAN HERMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:HERMAN
Last Name:GRUNERT
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 1:4607 WHITFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707
Mailing Address - Country:US
Mailing Address - Phone:919-489-9077
Mailing Address - Fax:
Practice Address - Street 1:5501 FORTUNES RIDGE DRIVE
Practice Address - Street 2:SUITE Q
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713
Practice Address - Country:US
Practice Address - Phone:919-489-1445
Practice Address - Fax:919-489-1445
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7993433Medicaid
NC93433OtherBCBS
NCU41491Medicare UPIN