Healthcare Provider Details

I. General information

NPI: 1881265395
Provider Name (Legal Business Name): RAQUELINE BRUNO DE SOUSA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RAQUELINE BRUNO DE SOUSA DDS

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 CLARK RD STE 410
SARASOTA FL
34231-8406
US

IV. Provider business mailing address

6211 SAWYER LOOP RD # APAT206
SARASOTA FL
34238-3069
US

V. Phone/Fax

Practice location:
  • Phone: 941-927-1705
  • Fax:
Mailing address:
  • Phone: 585-485-2703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number26224
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: