Healthcare Provider Details

I. General information

NPI: 1700145349
Provider Name (Legal Business Name): DDSDMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 MITCHAM DR SUITE #102
TALLAHASSEE FL
32308-5480
US

IV. Provider business mailing address

5716 FARNSWORTH DR
TALLAHASSEE FL
32312-4881
US

V. Phone/Fax

Practice location:
  • Phone: 850-425-1300
  • Fax: 850-219-1527
Mailing address:
  • Phone: 850-566-2972
  • Fax: 850-219-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN17786
License Number StateFL

VIII. Authorized Official

Name: DR. RICHARD JEAN-PIERRE BASTIEN
Title or Position: OWNER
Credential: D.M.D.
Phone: 850-566-2972