Provider Demographics
NPI:1699885269
Name:BRUNWORTH, RYAN TODD (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:TODD
Last Name:BRUNWORTH
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 1:504 E COLBY ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1165
Mailing Address - Country:US
Mailing Address - Phone:231-894-8814
Mailing Address - Fax:231-893-6505
Practice Address - Street 1:504 E COLBY ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1165
Practice Address - Country:US
Practice Address - Phone:231-894-8814
Practice Address - Fax:231-893-6505
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI19078122300000X
MI29010190781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4836927Medicaid