Provider Demographics
NPI:1730742701
Name:LANCE C. BAUTISTA DDS, INC.
Entity type:Organization
Organization Name:LANCE C. BAUTISTA DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-523-5437
Mailing Address - Street 1:1213 COFFEE RD STE E
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4229
Mailing Address - Country:US
Mailing Address - Phone:209-523-5437
Mailing Address - Fax:209-523-5436
Practice Address - Street 1:1213 COFFEE RD STE E
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4229
Practice Address - Country:US
Practice Address - Phone:209-523-5437
Practice Address - Fax:209-523-5436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty