Provider Demographics
NPI:1518350560
Name:BAUTISTA, ATHENA JACQUELINE-GAUTHIER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ATHENA
Middle Name:JACQUELINE-GAUTHIER
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3835
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3835
Mailing Address - Country:US
Mailing Address - Phone:206-548-3114
Mailing Address - Fax:206-762-6355
Practice Address - Street 1:9245 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-5569
Practice Address - Country:US
Practice Address - Phone:206-461-6981
Practice Address - Fax:206-461-8581
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60544747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist