Provider Demographics
NPI:1558467670
Name:BAUTISTA, ENRICO S (DMD)
Entity Type:Individual
Prefix:
First Name:ENRICO
Middle Name:S
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19509 S COQUINA WAY
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33332
Mailing Address - Country:US
Mailing Address - Phone:954-389-0078
Mailing Address - Fax:
Practice Address - Street 1:1776 N PINE ISLAND RD
Practice Address - Street 2:#300
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322
Practice Address - Country:US
Practice Address - Phone:954-916-0947
Practice Address - Fax:954-916-9994
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN159331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice