Provider Demographics
NPI:1548724669
Name:BRENTON BUNDRICK, DDS, PLLC
Entity type:Organization
Organization Name:BRENTON BUNDRICK, DDS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-960-3909
Mailing Address - Street 1:7204 E MARSHVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-1191
Mailing Address - Country:US
Mailing Address - Phone:704-981-1664
Mailing Address - Fax:
Practice Address - Street 1:7204 E MARSHVILLE BLVD
Practice Address - Street 2:
Practice Address - City:MARSHVILLE
Practice Address - State:NC
Practice Address - Zip Code:28103-1191
Practice Address - Country:US
Practice Address - Phone:704-981-1664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental