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General NPI Number Information
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NPI Number | 1114685740
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Entity Type | Organization
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Legal Business Name | BANSTOLA
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Dates
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Enumeration Date | 12/01/2021
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 2315 BROCKETT RD
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City | TUCKER
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State | GA
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Zip | 30084-4412
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Country | US
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Telephone | 770-934-1698
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2635
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City | TUCKER
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State | GA
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Zip | 30085-2635
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | BASU BANSTOLA
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Credential | DMD
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Telephone | 770-934-1698
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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