Provider Demographics
NPI:1235682808
Name:BATES, DAKOTA BLUE (MSW INTERN)
Entity Type:Individual
Prefix:
First Name:DAKOTA
Middle Name:BLUE
Last Name:BATES
Suffix:
Gender:M
Credentials:MSW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16575 MALLORY DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6610
Mailing Address - Country:US
Mailing Address - Phone:909-559-6895
Mailing Address - Fax:
Practice Address - Street 1:1556 S SULTANA AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-4238
Practice Address - Country:US
Practice Address - Phone:909-418-6923
Practice Address - Fax:909-418-6937
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program