Provider Demographics
NPI:1881746048
Name:BRENT R. UNRUH, DMD, PA
Entity type:Organization
Organization Name:BRENT R. UNRUH, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:UNRUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-664-0489
Mailing Address - Street 1:1717 LINCOLN WAY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2556
Mailing Address - Country:US
Mailing Address - Phone:208-664-0489
Mailing Address - Fax:208-769-7339
Practice Address - Street 1:1717 LINCOLN WAY
Practice Address - Street 2:SUITE 107
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2556
Practice Address - Country:US
Practice Address - Phone:208-664-0489
Practice Address - Fax:208-769-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17641223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty