Basic Information
| Provider Information | |||||||||
| NPI: | 1295324325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE GOUVEIA | ||||||||
| FirstName: | BRUNA | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA STE A | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 2625 MCNUTT RD | ||||||||
| Address2: | |||||||||
| City: | SUNLAND PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880639608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755891500 | ||||||||
| FaxNumber: | 5755891519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2021 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.00204620 | CO | N | Dental Providers | Dentist | 122300000X | DD5505 | NM | N | Dental Providers | Dentist | 1223G0001X | DD5505 | NM | Y | Dental Providers | Dentist | General Practice |
No ID Information.