Provider Demographics
NPI:1417633348
Name:PHILIPPE BAUTISTA DMD LLC
Entity Type:Organization
Organization Name:PHILIPPE BAUTISTA DMD LLC
Other - Org Name:PBJ KIDS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIPPE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-744-5442
Mailing Address - Street 1:434 PATROL RD SUITE 210
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130
Mailing Address - Country:US
Mailing Address - Phone:812-582-7255
Mailing Address - Fax:
Practice Address - Street 1:434 PATROL RD SUITE 210
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130
Practice Address - Country:US
Practice Address - Phone:812-582-7255
Practice Address - Fax:812-975-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty