Provider Demographics
NPI:1801908298
Name:BUSAN, MIA M (DDS)
Entity type:Individual
Prefix:DR
First Name:MIA
Middle Name:M
Last Name:BUSAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12546 VALLEY VIEW ST
Mailing Address - Street 2:B
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-2006
Mailing Address - Country:US
Mailing Address - Phone:714-895-4495
Mailing Address - Fax:
Practice Address - Street 1:12546 VALLEY VIEW ST
Practice Address - Street 2:B
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92845-2006
Practice Address - Country:US
Practice Address - Phone:714-895-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA380451223G0001X, 122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered122400000XDental ProvidersDenturist