Healthcare Provider Details

I. General information

NPI: 1992327456
Provider Name (Legal Business Name): NINA BUBALO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 WALNUT AVE STE 24
SAN DIEGO CA
92103-4980
US

IV. Provider business mailing address

306 WALNUT AVE STE 24
SAN DIEGO CA
92103-4980
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-1005
  • Fax:
Mailing address:
  • Phone: 619-232-1005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberE20969
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number107926
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: