Provider Demographics
NPI:1134987324
Name:BAUTISTA, BEATRICE ANNE (DMD)
Entity type:Individual
Prefix:
First Name:BEATRICE
Middle Name:ANNE
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 1:223 HUMMINGBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1141
Mailing Address - Country:US
Mailing Address - Phone:707-319-6101
Mailing Address - Fax:
Practice Address - Street 1:86-260 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3128
Practice Address - Country:US
Practice Address - Phone:808-697-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3158122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty