Provider Demographics
NPI:1194932152
Name:NIEVA SOCORRO R. BAUTISTA D.M.D., INC
Entity type:Organization
Organization Name:NIEVA SOCORRO R. BAUTISTA D.M.D., INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIEVA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-724-7645
Mailing Address - Street 1:1293 E VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-4039
Mailing Address - Country:US
Mailing Address - Phone:760-724-7645
Mailing Address - Fax:760-724-7640
Practice Address - Street 1:1293 E VISTA WAY
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4039
Practice Address - Country:US
Practice Address - Phone:760-724-7645
Practice Address - Fax:760-724-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47229305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization