Provider Demographics
NPI:1356342505
Name:BRUNSOMAN, JERRY KENT (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:KENT
Last Name:BRUNSOMAN
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:1774 COPE AVE E
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2662
Mailing Address - Country:US
Mailing Address - Phone:651-774-9611
Mailing Address - Fax:651-748-3704
Practice Address - Street 1:1774 COPE AVE E
Practice Address - Street 2:SUITE 140
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2662
Practice Address - Country:US
Practice Address - Phone:651-774-9611
Practice Address - Fax:651-748-3704
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MND69501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT39435Medicare UPIN