Individual
DR. MARK GREGORY BRUNK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Contact information
Practice address
607 W ORCHARD ST, VANDALIA, IL 62471-1234
(618) 283-2929
(618) 283-2113
Mailing address
607 W ORCHARD ST, VANDALIA, IL 62471-1234
(618) 283-2929
(618) 283-2113
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019019107
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0587318
COMPDENT FACILITY#
IL
05
—
1001332
—
IL
01
—
371175219
TAX ID#
IL
01
—
623475
UNITED CONCORDIA#
IL
01
—
DNIL19107A
BCBS ID#
IL
Enumeration date
11/22/2006
Last updated
07/09/2007
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