Provider Demographics
NPI:1770526451
Name:BRUNSON, MATTHEW A (DDS)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:A
Last Name:BRUNSON
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 1:3226 E ELIDA ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3221
Mailing Address - Country:US
Mailing Address - Phone:734-730-1035
Mailing Address - Fax:
Practice Address - Street 1:SELLS HOSPITAL
Practice Address - Street 2:HWY 86
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634-8563
Practice Address - Country:US
Practice Address - Phone:928-226-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0082121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ871683Medicaid
8EC751Medicare ID - Type Unspecified
V09155Medicare UPIN