Provider Demographics
NPI:1548488695
Name:BAUTISTA, RANDY B (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:B
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 1:140 GREGORY LN
Mailing Address - Street 2:SUITE #200
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-3399
Mailing Address - Country:US
Mailing Address - Phone:650-892-4268
Mailing Address - Fax:
Practice Address - Street 1:140 GREGORY LN
Practice Address - Street 2:SUITE #200
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-3399
Practice Address - Country:US
Practice Address - Phone:650-892-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53577122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist