1245355312 NPI number — DAVID C BASTACKY DMD PA

Table of content: (NPI 1245355312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245355312 NPI number — DAVID C BASTACKY DMD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID C BASTACKY DMD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245355312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 N ROLLING RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-4140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-744-4222
Provider Business Mailing Address Fax Number:
410-744-2472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 N ROLLING RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-744-4222
Provider Business Practice Location Address Fax Number:
410-744-2472
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BASTACKY
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR OWNER
Authorized Official Telephone Number:
410-744-4222

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  10337 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: N930 62930 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: S164 . This is a "DENTAL NETWORK" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 795229 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2038621 . This is a "AETNA MEDICAL HMO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 42602402 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 210589 . This is a "MDIPA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3822 . This is a "FED MED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 168250000 . This is a "PHN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4141305 . This is a "AETNA DENTAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2715 . This is a "DHA FORTIS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 93918-1 . This is a "DENTAL BENEFIT PROVIDERS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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