Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | D10643 | MN |
NPI | 1083789572 |
---|---|
Provider Name | Dr. Brent Donald Rundquist |
First Address | Plymouth, MN 55441-2413 |
Second Address | Plymouth, MN 55441-2413 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2006 |
Last Update Date | 08/07/2007 |