Provider Demographics
NPI:1467067967
Name:BUESO, VASHTI
Entity Type:Individual
Prefix:DR
First Name:VASHTI
Middle Name:
Last Name:BUESO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VASHTI
Other - Middle Name:
Other - Last Name:ECKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1355 W FILLMORE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-0023
Mailing Address - Country:US
Mailing Address - Phone:707-502-6176
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:077-502-6176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0342531223E0200X
ORD113291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty