Healthcare Provider Details

I. General information

NPI: 1275532384
Provider Name (Legal Business Name): BRUNO CRISTALLI DA COSTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 NW FLANDERS ST 112
PORTLAND OR
97210-3443
US

IV. Provider business mailing address

2250 NW FLANDERS ST 112
PORTLAND OR
97210-3443
US

V. Phone/Fax

Practice location:
  • Phone: 503-248-1970
  • Fax: 503-248-6811
Mailing address:
  • Phone: 503-248-1970
  • Fax: 503-248-6811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8550
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: