Healthcare Provider Details

I. General information

NPI: 1245355312
Provider Name (Legal Business Name): DAVID C BASTACKY DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 N ROLLING RD SUITE 104
BALTIMORE MD
21228-4140
US

IV. Provider business mailing address

516 N ROLLING RD SUITE 104
BALTIMORE MD
21228-4140
US

V. Phone/Fax

Practice location:
  • Phone: 410-744-4222
  • Fax: 410-744-2472
Mailing address:
  • Phone: 410-744-4222
  • Fax: 410-744-2472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10337
License Number StateMD

VIII. Authorized Official

Name: DR. DAVID BASTACKY
Title or Position: DOCTOR OWNER
Credential: DMD PA
Phone: 410-744-4222