Provider Demographics
NPI:1740978642
Name:BRUNSON, AUSTIN JOHN
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JOHN
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 PACIFIC PL SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3568
Mailing Address - Country:US
Mailing Address - Phone:541-926-6089
Mailing Address - Fax:
Practice Address - Street 1:3120 PACIFIC PL SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3568
Practice Address - Country:US
Practice Address - Phone:541-926-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist