Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 126800000X | Dental Assistant | 86307 | CA |
NPI | 1245854231 |
---|---|
Provider Name | Teylor Bustamante |
First Address | Lake Forest, CA 92630-4311 |
Second Address | Mission Viejo, CA 92691-6724 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2020 |
Last Update Date | 04/06/2020 |