Healthcare Provider Details

I. General information

NPI: 1104108398
Provider Name (Legal Business Name): STARFISH FAIRHOPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10040 COUNTY ROAD 48
FAIRHOPE AL
36532
US

IV. Provider business mailing address

4451 BLUEBONNET BLVD SUITE F
BATON ROUGE LA
70809
US

V. Phone/Fax

Practice location:
  • Phone: 251-928-0131
  • Fax:
Mailing address:
  • Phone: 225-767-2273
  • Fax: 225-769-3395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANDRE BRUNI
Title or Position: OWNER
Credential: DDS
Phone: 225-767-2273