Provider Demographics
NPI:1306194782
Name:BUSTAMANTE, DAN (DC)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-2031
Mailing Address - Country:US
Mailing Address - Phone:575-513-9430
Mailing Address - Fax:
Practice Address - Street 1:412 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-2031
Practice Address - Country:US
Practice Address - Phone:575-513-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor