Healthcare Provider Details

I. General information

NPI: 1477605764
Provider Name (Legal Business Name): BRYAN IVAN BARIENTOS D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 WHARF RD
BOLINAS CA
94924
US

IV. Provider business mailing address

PO BOX 837
BOLINAS CA
94924-0837
US

V. Phone/Fax

Practice location:
  • Phone: 415-868-0168
  • Fax: 415-868-1304
Mailing address:
  • Phone: 415-868-0168
  • Fax: 415-868-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: