Provider Demographics
NPI:1316600430
Name:BUBUKINA, KSENIA
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:BUBUKINA
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 1:714 TIVERTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16071 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3405
Practice Address - Country:US
Practice Address - Phone:714-536-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2023-11-20
Deactivation Date:2023-10-22
Deactivation Code:
Reactivation Date:2023-11-08
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA1088371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
XDP801667280OtherUC SHIP