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General NPI Number Information
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NPI Number | 1063860930
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Entity Type | Individual
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Provider Name | CARISSA BRUENING D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 06/01/2016
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Last Update Date | 06/23/2016
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Provider Practice Location Address
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Address Line | 130 HILLTOWN VILLAGE CTR
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City | CHESTERFIELD
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State | MO
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Zip | 63017-0709
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Country | US
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Telephone | 636-532-3311
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Fax |
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Provider Business Mailing Address
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Address Line | 1387 NORWOOD HILLS DR
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City | O FALLON
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State | MO
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Zip | 63366-5561
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Country | US
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Telephone | 316-680-9116
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2016016881
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License Number State | MO
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