Provider Demographics
NPI:1639428493
Name:MONTEIRO, BRUNO
Entity Type:Individual
Prefix:
First Name:BRUNO
Middle Name:
Last Name:MONTEIRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ABBOTSFORD ST
Mailing Address - Street 2:APT. #3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02121-1409
Mailing Address - Country:US
Mailing Address - Phone:617-820-0326
Mailing Address - Fax:
Practice Address - Street 1:520 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2769
Practice Address - Country:US
Practice Address - Phone:617-989-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA097615OtherBLUE SHIELD