Provider Demographics
NPI:1396763991
Name:BAUTISTA, VIRGILIO SERRA (DMD)
Entity type:Individual
Prefix:DR
First Name:VIRGILIO
Middle Name:SERRA
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46533 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-7993
Mailing Address - Country:US
Mailing Address - Phone:510-475-8668
Mailing Address - Fax:510-445-1045
Practice Address - Street 1:46533 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-7993
Practice Address - Country:US
Practice Address - Phone:510-475-8668
Practice Address - Fax:510-445-1045
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA388021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice