Provider Demographics
NPI:1114121753
Name:BRUAN, EDBERT R (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDBERT
Middle Name:R
Last Name:BRUAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1012
Mailing Address - Country:US
Mailing Address - Phone:818-247-9044
Mailing Address - Fax:818-247-9044
Practice Address - Street 1:2906 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1012
Practice Address - Country:US
Practice Address - Phone:818-247-9044
Practice Address - Fax:818-247-9044
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA380141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice