Basic Information
| Provider Information | |||||||||
| NPI: | 1518629872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUENING | ||||||||
| FirstName: | KAITLYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | RDH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1440 | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549821440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S TOWNLINE RD | ||||||||
| Address2: | |||||||||
| City: | WAUTOMA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549826922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207875514 | ||||||||
| FaxNumber: | 9207874737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2021 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 1003166 | WI | Y | Dental Providers | Dental Hygienist |
No ID Information.