Provider Demographics
NPI:1912170341
Name:KENNETH L. BRUNSON, DDS, MS, PC
Entity Type:Organization
Organization Name:KENNETH L. BRUNSON, DDS, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:731-285-9657
Mailing Address - Street 1:1950 US HIGHWAY 51 BYP N
Mailing Address - Street 2:SUITE A
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-1896
Mailing Address - Country:US
Mailing Address - Phone:731-285-9657
Mailing Address - Fax:731-285-0055
Practice Address - Street 1:1950 US HIGHWAY 51 BYP N
Practice Address - Street 2:SUITE A
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1896
Practice Address - Country:US
Practice Address - Phone:731-285-9657
Practice Address - Fax:731-285-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS18261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN18158OtherDORAL DENTAL USA