Provider Demographics
NPI:1841807336
Name:BUN, CHANVATTANAK
Entity Type:Individual
Prefix:
First Name:CHANVATTANAK
Middle Name:
Last Name:BUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-2637
Mailing Address - Country:US
Mailing Address - Phone:714-599-4393
Mailing Address - Fax:
Practice Address - Street 1:1201 24TH ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2300
Practice Address - Country:US
Practice Address - Phone:714-599-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1055991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice