Provider Demographics
NPI:1306116512
Name:WANNARKA, ANA BUENDIA
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:BUENDIA
Last Name:WANNARKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 W 34TH ST
Mailing Address - Street 2:DEN 4230 M/C 0641
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-0641
Mailing Address - Country:US
Mailing Address - Phone:213-740-8663
Mailing Address - Fax:
Practice Address - Street 1:925 W 34TH ST
Practice Address - Street 2:DEN 4230 M/C 0641
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0641
Practice Address - Country:US
Practice Address - Phone:213-740-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60194063122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist