Provider Demographics
NPI:1194160341
Name:BUSTAMANTE, MIGUEL ISMAEL (DDS)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ISMAEL
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 975
Mailing Address - Street 2:
Mailing Address - City:BOLINAS
Mailing Address - State:CA
Mailing Address - Zip Code:94924-0975
Mailing Address - Country:US
Mailing Address - Phone:415-868-0911
Mailing Address - Fax:415-868-2324
Practice Address - Street 1:24 WHARF ROAD
Practice Address - Street 2:
Practice Address - City:BOLINAS
Practice Address - State:CA
Practice Address - Zip Code:94924
Practice Address - Country:US
Practice Address - Phone:415-868-0911
Practice Address - Fax:415-868-2324
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0348211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice