Provider Demographics
NPI:1578853503
Name:BAUTISTA, DONNA (DDS)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
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 1:26137 LA PAZ RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5319
Mailing Address - Country:US
Mailing Address - Phone:949-226-7222
Mailing Address - Fax:949-581-5454
Practice Address - Street 1:26137 LA PAZ RD
Practice Address - Street 2:SUITE 270
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5319
Practice Address - Country:US
Practice Address - Phone:949-226-7222
Practice Address - Fax:949-581-5454
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42906122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist