Healthcare Provider Details

I. General information

NPI: 1851903777
Provider Name (Legal Business Name): CLIFFORD JOSEPH BAUTISTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-4178
  • Fax: 757-953-0844
Mailing address:
  • Phone: 757-953-4178
  • Fax: 757-953-0844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number35980
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: