Provider Demographics
NPI:1881265395
Name:BRUNO DE SOUSA, RAQUELINE (DDS)
Entity type:Individual
Prefix:
First Name:RAQUELINE
Middle Name:
Last Name:BRUNO DE SOUSA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:RAQUELINE
Other - Middle Name:
Other - Last Name:BRUNO DE SOUSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:6211 SAWYER LOOP RD # APAT206
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-3069
Mailing Address - Country:US
Mailing Address - Phone:585-485-2703
Mailing Address - Fax:
Practice Address - Street 1:3466 CLARK RD STE 410
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8406
Practice Address - Country:US
Practice Address - Phone:941-927-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL262241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice