Provider Demographics
NPI:1073087847
Name:BUSTAMANTE, CHRISTINE
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 RIO RANCHO RD STE 120
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-7015
Mailing Address - Country:US
Mailing Address - Phone:909-243-7939
Mailing Address - Fax:
Practice Address - Street 1:763 RIO RANCHO RD STE 120
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-7015
Practice Address - Country:US
Practice Address - Phone:909-243-7939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77989126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77989Medicaid