Provider Demographics
NPI:1902158801
Name:BAUTISTA, EDGAR GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDGAR GARY
Middle Name:
Last Name:BAUTISTA
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 1:81 IRVING PLACE,
Mailing Address - Street 2:SUITE 1-D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2257
Mailing Address - Country:US
Mailing Address - Phone:212-260-2652
Mailing Address - Fax:212-533-3331
Practice Address - Street 1:81 IRVING PLACE
Practice Address - Street 2:SUITE 1-D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2257
Practice Address - Country:US
Practice Address - Phone:212-260-2652
Practice Address - Fax:212-533-3331
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0340021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice