Provider Demographics
NPI:1639747082
Name:DATU, BUENAVENTURA CAGUIOA (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:MR
First Name:BUENAVENTURA
Middle Name:CAGUIOA
Last Name:DATU
Suffix:
Gender:M
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DENTAL HYGIENIST
Mailing Address - Street 1:2960 LAKELAND HIGHLAND
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2960 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4370
Practice Address - Country:US
Practice Address - Phone:863-665-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20635124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist