Provider Demographics
NPI:1871668012
Name:BRUNK, MARK GREGORY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GREGORY
Last Name:BRUNK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1234
Mailing Address - Country:US
Mailing Address - Phone:618-283-2929
Mailing Address - Fax:618-283-2113
Practice Address - Street 1:607 W ORCHARD ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1234
Practice Address - Country:US
Practice Address - Phone:618-283-2929
Practice Address - Fax:618-283-2113
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190191071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371175219OtherTAX ID#
IL0587318OtherCOMPDENT FACILITY#
IL623475OtherUNITED CONCORDIA#
IL1001332Medicaid
ILDNIL19107AOtherBCBS ID#