Provider Demographics
NPI:1407488646
Name:BAUTISTA, LIBIA ELENA
Entity Type:Individual
Prefix:
First Name:LIBIA
Middle Name:ELENA
Last Name:BAUTISTA
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 1:3857 DURFEE AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-2505
Mailing Address - Country:US
Mailing Address - Phone:626-766-9705
Mailing Address - Fax:
Practice Address - Street 1:2604 S VERMONT AVE STE F
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-2298
Practice Address - Country:US
Practice Address - Phone:323-731-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA91293126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant