Provider Demographics
NPI:1093969214
Name:BLUEBONNET DENTAL CARE @ CORDOBA
Entity Type:Organization
Organization Name:BLUEBONNET DENTAL CARE @ CORDOBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:337-456-5573
Mailing Address - Street 1:4451 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9646
Mailing Address - Country:US
Mailing Address - Phone:225-767-2273
Mailing Address - Fax:
Practice Address - Street 1:4906 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:BUILDING I
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6962
Practice Address - Country:US
Practice Address - Phone:337-456-5573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty