Healthcare Provider Details

I. General information

NPI: 1306311634
Provider Name (Legal Business Name): MISS MILES BUNOAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2018
Last Update Date: 10/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 N TUSTIN ST
ORANGE CA
92867-7716
US

IV. Provider business mailing address

3350 BALTIC AVE
LONG BEACH CA
90810-2320
US

V. Phone/Fax

Practice location:
  • Phone: 562-606-7325
  • Fax:
Mailing address:
  • Phone: 562-606-7325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number89203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: