Provider Demographics
NPI:1528680824
Name:BRUNSON, JORDAN TYLER (DMD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:TYLER
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5307 E MOCKINGBIRD LN STE 325
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-5109
Mailing Address - Country:US
Mailing Address - Phone:214-821-5011
Mailing Address - Fax:
Practice Address - Street 1:4898 LITTLE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1054
Practice Address - Country:US
Practice Address - Phone:614-668-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX36152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program