Provider Demographics
NPI:1003958745
Name:BUENAVENTURA, MIRIAM BAUTISTA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:BAUTISTA
Last Name:BUENAVENTURA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MIRIAM
Other - Middle Name:BAUTISTA
Other - Last Name:BUENAVENTURA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5031 EAGLE ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1923
Mailing Address - Country:US
Mailing Address - Phone:323-256-6428
Mailing Address - Fax:323-256-8439
Practice Address - Street 1:5031 EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1923
Practice Address - Country:US
Practice Address - Phone:323-256-6428
Practice Address - Fax:323-256-8439
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA460301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice