Provider Demographics
NPI:1538901889
Name:BRUNELLE, TATE PARKER (DDS)
Entity type:Individual
Prefix:
First Name:TATE
Middle Name:PARKER
Last Name:BRUNELLE
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 1:3608 FARAON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3044
Mailing Address - Country:US
Mailing Address - Phone:816-364-6444
Mailing Address - Fax:
Practice Address - Street 1:3608 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3044
Practice Address - Country:US
Practice Address - Phone:816-364-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-08
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024021112122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist