Provider Demographics
NPI:1649658899
Name:KULOBA, BRUNO
Entity type:Individual
Prefix:
First Name:BRUNO
Middle Name:
Last Name:KULOBA
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 1:1236 SANDBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5207
Mailing Address - Country:US
Mailing Address - Phone:850-449-6154
Mailing Address - Fax:
Practice Address - Street 1:1236 SANDBROOK DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-5207
Practice Address - Country:US
Practice Address - Phone:850-449-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN216501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program