Provider Demographics
NPI:1245066885
Name:SUNGA, ELLYSHA BAUTISTA (DDS)
Entity type:Individual
Prefix:
First Name:ELLYSHA
Middle Name:BAUTISTA
Last Name:SUNGA
Suffix:
Gender:F
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:PO BOX 590921
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94159-0921
Mailing Address - Country:US
Mailing Address - Phone:619-446-7376
Mailing Address - Fax:
Practice Address - Street 1:3200 FULTON ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3713
Practice Address - Country:US
Practice Address - Phone:415-367-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1096601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice