Provider Demographics
NPI:1902116288
Name:GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Entity type:Organization
Organization Name:GREAT LAKES ORAL & MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BRUNTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-351-1010
Mailing Address - Street 1:1200 CREST VIEW DR STE 1
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-9391
Mailing Address - Country:US
Mailing Address - Phone:715-381-7070
Mailing Address - Fax:715-381-0383
Practice Address - Street 1:1200 CREST VIEW DR STE 1
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-9391
Practice Address - Country:US
Practice Address - Phone:715-381-7070
Practice Address - Fax:715-381-0383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty