1386016749 NPI number — L. RANDY BUNTYN, D.M.D. , PLLC

Table of content: GLENN PATTERSON MILLER JR. M.D. (NPI 1427233006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386016749 NPI number — L. RANDY BUNTYN, D.M.D. , PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L. RANDY BUNTYN, D.M.D. , PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386016749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1203 GOVERNMENT ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCEAN SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-875-3343
Provider Business Mailing Address Fax Number:
228-872-9794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1203 GOVERNMENT ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEAN SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-875-3343
Provider Business Practice Location Address Fax Number:
228-872-9794
Provider Enumeration Date:
10/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BUNTYN
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
ROSS
Authorized Official Title or Position:
PRESIDENT/MANAGER
Authorized Official Telephone Number:
228-875-3343

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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