Provider Demographics
NPI:1073251963
Name:BUSTOS THACKER, ANGELICA JANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANGELICA JANE
Middle Name:
Last Name:BUSTOS THACKER
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 1:12028 HATHAWAY PINES LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-4501
Mailing Address - Country:US
Mailing Address - Phone:702-883-9376
Mailing Address - Fax:
Practice Address - Street 1:7603 GRAND TETON DR STE 140
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-1602
Practice Address - Country:US
Practice Address - Phone:702-957-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-22
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV76171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice