Provider Demographics
NPI:1487930004
Name:BETH BRUNNER, DMD, PLLC
Entity type:Organization
Organization Name:BETH BRUNNER, DMD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD, PLLC
Authorized Official - Phone:518-837-5019
Mailing Address - Street 1:1936 SARANAC AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-1114
Mailing Address - Country:US
Mailing Address - Phone:518-837-5019
Mailing Address - Fax:518-837-5093
Practice Address - Street 1:1936 SARANAC AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-1114
Practice Address - Country:US
Practice Address - Phone:518-837-5019
Practice Address - Fax:518-837-5093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054553261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental