Healthcare Provider Details

I. General information

NPI: 1710074513
Provider Name (Legal Business Name): BUSTAMANTE ENDODONTICS ADC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 WILSHIRE BLVD SUITE 1160
LOS ANGELES CA
90025-6811
US

IV. Provider business mailing address

11645 WILSHIRE BLVD SUITE 1160
LOS ANGELES CA
90025-6811
US

V. Phone/Fax

Practice location:
  • Phone: 310-473-5559
  • Fax:
Mailing address:
  • Phone: 310-473-5559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number29218
License Number StateCA

VIII. Authorized Official

Name: DR. MANUEL A. BUSTAMANTE
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 310-473-5559