Basic Information
| Provider Information | |||||||||
| NPI: | 1467681601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNACINI | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULTZ | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 389 CONGRESS ST. | ||||||||
| Address2: | THE CITY OF PORTLAND, PUBLIC HEALTH DIVISION | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078748944 | ||||||||
| FaxNumber: | 2078748913 | ||||||||
| Practice Location | |||||||||
| Address1: | 284 CUMBERLAND AVE. | ||||||||
| Address2: | PORTLAND HIGH SCHOOL, AMANDA ROWE HEALTH CLINIC | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078424653 | ||||||||
| FaxNumber: | 2078288802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2009 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN4114 | ME | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 434739499 | 05 | ME | MEDICAID |