Provider Demographics
NPI:1013084532
Name:BAUTISTA, NIEVA R (DMD)
Entity Type:Individual
Prefix:
First Name:NIEVA
Middle Name:R
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1293 E VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-4039
Mailing Address - Country:US
Mailing Address - Phone:760-724-7645
Mailing Address - Fax:760-724-7640
Practice Address - Street 1:1293 E VISTA WAY
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4039
Practice Address - Country:US
Practice Address - Phone:760-724-7645
Practice Address - Fax:760-724-7640
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice