Provider Demographics
NPI:1235128992
Name:BRUNTON, RICHARD WILLIAM (DDS)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:BRUNTON
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 1:15270 PAINTERS LANE CIR N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-1642
Mailing Address - Country:US
Mailing Address - Phone:651-436-4145
Mailing Address - Fax:
Practice Address - Street 1:2850 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-4079
Practice Address - Country:US
Practice Address - Phone:651-351-1010
Practice Address - Fax:651-351-9333
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN107621223S0112X
WI44821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33714200Medicaid
WI0000179110Medicare ID - Type UnspecifiedWI MEDICARE #
WI33714200Medicaid