Provider Demographics
NPI:1831230101
Name:BAGUS, RENE AYTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:RENE
Middle Name:AYTIN
Last Name:BAGUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 PARK ST
Mailing Address - Street 2:#100
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6295
Mailing Address - Country:US
Mailing Address - Phone:510-522-4215
Mailing Address - Fax:
Practice Address - Street 1:450 PARK ST
Practice Address - Street 2:#100
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-6295
Practice Address - Country:US
Practice Address - Phone:510-522-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA488821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice