Provider Demographics
NPI:1245388867
Name:BUSTAMANTE, PRISCILLA SOLIMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:SOLIMAN
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3748 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1528
Mailing Address - Country:US
Mailing Address - Phone:323-669-1555
Mailing Address - Fax:323-669-7908
Practice Address - Street 1:3748 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-1528
Practice Address - Country:US
Practice Address - Phone:323-669-1555
Practice Address - Fax:323-669-7908
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA265971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice