Provider Demographics
NPI:1063860930
Name:BRUENING, CARISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:
Last Name:BRUENING
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1387 NORWOOD HILLS DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-5561
Mailing Address - Country:US
Mailing Address - Phone:316-680-9116
Mailing Address - Fax:
Practice Address - Street 1:130 HILLTOWN VILLAGE CTR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-0709
Practice Address - Country:US
Practice Address - Phone:636-532-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016016881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist