Provider Demographics
NPI:1508008467
Name:BUSTILLOS, CAROLYN D
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:D
Last Name:BUSTILLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:D
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:BUILDING N-46 CAPE SARICHEF
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99619-5002
Mailing Address - Country:US
Mailing Address - Phone:907-487-5757
Mailing Address - Fax:907-487-5360
Practice Address - Street 1:BUILDING N-46 CAPE SARICHEF
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99619-5002
Practice Address - Country:US
Practice Address - Phone:907-487-5757
Practice Address - Fax:907-487-5360
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38985126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant