Healthcare Provider Details

I. General information

NPI: 1780315952
Provider Name (Legal Business Name): JUSTIN R DEGUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 CALLOWAY DR STE 401
BAKERSFIELD CA
93312-2529
US

IV. Provider business mailing address

3409 CALLOWAY DR STE 401
BAKERSFIELD CA
93312-2529
US

V. Phone/Fax

Practice location:
  • Phone: 661-410-1234
  • Fax:
Mailing address:
  • Phone: 661-410-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number108438
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: