Provider Demographics
NPI:1053084756
Name:BUSTOS, SARA CAMILA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:CAMILA
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W ROSEDALE ST APT 420
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3577
Mailing Address - Country:US
Mailing Address - Phone:617-646-9268
Mailing Address - Fax:
Practice Address - Street 1:3154 S STATE HIGHWAY 161 STE 640
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7687
Practice Address - Country:US
Practice Address - Phone:972-890-0718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist