Basic Information
| Provider Information | |||||||||
| NPI: | 1770526451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3226 E ELIDA ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857163221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347301035 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | SELLS HOSPITAL | ||||||||
| Address2: | HWY 86 | ||||||||
| City: | SELLS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856348563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282267494 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | D008212 | AZ | Y | Dental Providers | Dentist | Endodontics |
ID Information
| ID | Type | State | Issuer | Description | 871683 | 05 | AZ | MEDICAID |