Provider Demographics
NPI:1871223131
Name:BAUTISTA, GILBERT EVANGELISTA
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:EVANGELISTA
Last Name:BAUTISTA
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 1:5800 N INTERSTATE 35 STE 205
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-1438
Mailing Address - Country:US
Mailing Address - Phone:940-220-7833
Mailing Address - Fax:
Practice Address - Street 1:810 S GENERAL MCMULLEN DR STE 108
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-3163
Practice Address - Country:US
Practice Address - Phone:210-485-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX386341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice