Provider Demographics
NPI:1396919973
Name:BAUTISTA, JESSICA ABRENIO (DDS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ABRENIO
Last Name:BAUTISTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18590 VAN BUREN BLVD
Mailing Address - Street 2:SUITE 2-B
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-9109
Mailing Address - Country:US
Mailing Address - Phone:951-776-9772
Mailing Address - Fax:
Practice Address - Street 1:2094 W REDLANDS BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-6221
Practice Address - Country:US
Practice Address - Phone:909-335-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA567831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice