Provider Demographics
NPI:1245854231
Name:BUSTAMANTE, TEYLOR
Entity type:Individual
Prefix:
First Name:TEYLOR
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25602 HAZELNUT LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25982 PALA STE 130
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6724
Practice Address - Country:US
Practice Address - Phone:949-317-6076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86307126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant