Healthcare Provider Details

I. General information

NPI: 1194160341
Provider Name (Legal Business Name): MIGUEL ISMAEL BUSTAMANTE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 WHARF ROAD
BOLINAS CA
94924
US

IV. Provider business mailing address

PO BOX 975
BOLINAS CA
94924-0975
US

V. Phone/Fax

Practice location:
  • Phone: 415-868-0911
  • Fax: 415-868-2324
Mailing address:
  • Phone: 415-868-0911
  • Fax: 415-868-2324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number034821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: