Provider Demographics
NPI:1417138892
Name:EBBAY, PURITA BANGASAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:PURITA
Middle Name:BANGASAN
Last Name:EBBAY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 E PLAZA BLVD
Mailing Address - Street 2:#C
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950
Mailing Address - Country:US
Mailing Address - Phone:619-477-1577
Mailing Address - Fax:619-477-6014
Practice Address - Street 1:1105 E PLAZA BLVD
Practice Address - Street 2:STE C
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950
Practice Address - Country:US
Practice Address - Phone:619-477-1577
Practice Address - Fax:619-477-6014
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39789122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist