Healthcare Provider Details

I. General information

NPI: 1366245961
Provider Name (Legal Business Name): CRISTAL BRUCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2025
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE STE 111
NORWALK CT
06851-1080
US

IV. Provider business mailing address

761 MAIN AVE STE 111
NORWALK CT
06851-1080
US

V. Phone/Fax

Practice location:
  • Phone: 203-908-3170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number14695
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: