Healthcare Provider Details

I. General information

NPI: 1942432273
Provider Name (Legal Business Name): JONATHAN BUENJEMIA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9193 SIERRA AVE SUITE B
FONTANA CA
92335-4776
US

IV. Provider business mailing address

11684 LARGO CT
LOMA LINDA CA
92354-3973
US

V. Phone/Fax

Practice location:
  • Phone: 909-355-0485
  • Fax:
Mailing address:
  • Phone: 909-224-4830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number58437
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: