Provider Demographics
NPI:1962544858
Name:BUSTOS, JORGE EDGARDO (DDS)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:EDGARDO
Last Name:BUSTOS
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 1:30630 RANCHO CALIFORNIA RD
Mailing Address - Street 2:SUITE 504
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3283
Mailing Address - Country:US
Mailing Address - Phone:951-694-0545
Mailing Address - Fax:
Practice Address - Street 1:30630 RANCHO CALIFORNIA RD
Practice Address - Street 2:SUITE 504
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-3283
Practice Address - Country:US
Practice Address - Phone:951-694-0545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice