Provider Demographics
NPI:1609188259
Name:BRUNO, CANDACE LAUREN (DMD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:LAUREN
Last Name:BRUNO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7416 TURNBUOY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-4333
Mailing Address - Country:US
Mailing Address - Phone:619-261-4073
Mailing Address - Fax:
Practice Address - Street 1:11410 JOLLYVILLE RD
Practice Address - Street 2:3102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4097
Practice Address - Country:US
Practice Address - Phone:512-372-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0025624122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2128852-01Medicaid