Provider Demographics
NPI:1235343781
Name:BLUEBONNET DENTAL CARE
Entity Type:Organization
Organization Name:BLUEBONNET DENTAL CARE
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:
Authorized Official - Phone:225-767-2273
Mailing Address - Street 1:4451 BLUEBONNET BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-9639
Mailing Address - Country:US
Mailing Address - Phone:225-767-2273
Mailing Address - Fax:225-769-3395
Practice Address - Street 1:4451 BLUEBONNET BLVD
Practice Address - Street 2:STE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-9639
Practice Address - Country:US
Practice Address - Phone:225-767-2273
Practice Address - Fax:225-769-3395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty