Provider Demographics
NPI:1912071085
Name:BANTA, DANTE ATIENZA (MD)
Entity Type:Individual
Prefix:DR
First Name:DANTE
Middle Name:ATIENZA
Last Name:BANTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-3759
Mailing Address - Country:US
Mailing Address - Phone:323-258-7568
Mailing Address - Fax:323-258-7498
Practice Address - Street 1:875 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-3759
Practice Address - Country:US
Practice Address - Phone:323-258-7568
Practice Address - Fax:323-258-7498
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A440791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A440791OtherBLUE CROSS BLUE SHIELD
CA00A440791Medicaid
F51340Medicare UPIN
CA00A440791Medicaid