Provider Demographics
NPI:1104108398
Name:STARFISH FAIRHOPE
Entity type:Organization
Organization Name:STARFISH FAIRHOPE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-767-2273
Mailing Address - Street 1:4451 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809
Mailing Address - Country:US
Mailing Address - Phone:225-767-2273
Mailing Address - Fax:225-769-3395
Practice Address - Street 1:10040 COUNTY ROAD 48
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532
Practice Address - Country:US
Practice Address - Phone:251-928-0131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty