MEDICARE: BLUEBONNET DENTAL CARE @ CORDOBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5315	LA

General Provider Information

NPI Number	:	1093969214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET DENTAL CARE @ CORDOBA

Provider Business Mailing Address
First Line	:	4451 BLUEBONNET BLVD
Second Line	:	SUITE A
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-9646
Country	:	US
Telephone Number	:	225-767-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	4906 AMBASSADOR CAFFERY PKWY
Second Line	:	BUILDING I
City	:	LAFAYETTE
State	:	LA
Zip	:	70508-6962
Country	:	US
Telephone Number	:	337-456-5573
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANDRE BRUNI
Credential	:	DDS
Telephone Number	:	337-456-5573

Provider Enumeration Date	:	11/14/2008
Last Update Date	:	11/14/2008

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