Healthcare Provider Details

I. General information

NPI: 1316600430
Provider Name (Legal Business Name): KSENIA BUBUKINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date: 10/22/2023
Reactivation Date: 11/08/2023

III. Provider practice location address

16071 GOLDENWEST ST
HUNTINGTON BEACH CA
92647-3405
US

IV. Provider business mailing address

714 TIVERTON AVE
LOS ANGELES CA
90095-8361
US

V. Phone/Fax

Practice location:
  • Phone: 714-536-2383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number108837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: