Healthcare Provider Details

I. General information

NPI: 1285692731
Provider Name (Legal Business Name): EAST BAY ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 PAWTUCKET AVENUE
EAST PROVIDENCE RI
02914
US

IV. Provider business mailing address

2224 PAWTUCKET AVENUE
EAST PROVIDENCE RI
02914
US

V. Phone/Fax

Practice location:
  • Phone: 401-435-4240
  • Fax: 401-435-4245
Mailing address:
  • Phone: 401-435-4240
  • Fax: 401-435-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1686
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number16987
License Number StateMA

VIII. Authorized Official

Name: DR. STEPHEN NICHOLAS BAKIAS
Title or Position: OWNER
Credential: DDS
Phone: 401-435-4240