Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | DN013859 | GA |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 053375 | GA |
NPI | 1457672958 |
---|---|
Provider Name | Dr. Daniel Paul Brunner |
First Address | Marietta, GA 30062-8826 |
Second Address | Marietta, GA 30062-8826 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2010 |
Last Update Date | 22/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
402170337B | (05) | GA |