Provider Demographics
NPI:1699950329
Name:BAUTISTA, GREGORIO WAYNE (DMD)
Entity type:Individual
Prefix:
First Name:GREGORIO
Middle Name:WAYNE
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:G
Other - Middle Name:WAYNE
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:4719 LEGACY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-2067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 E OAK ST STE A
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744
Practice Address - Country:US
Practice Address - Phone:407-847-2103
Practice Address - Fax:407-847-5042
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN130331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017646700Medicaid
FLBB3721063OtherDEA
FL017646700Medicaid