Provider Demographics
NPI:1962146738
Name:BRAVO, RENATO ULISES
Entity type:Individual
Prefix:DR
First Name:RENATO
Middle Name:ULISES
Last Name:BRAVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3878 HENSON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93656-9215
Mailing Address - Country:US
Mailing Address - Phone:559-824-9479
Mailing Address - Fax:
Practice Address - Street 1:1350 E VISTA WAY STE 10
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4037
Practice Address - Country:US
Practice Address - Phone:760-208-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist