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General NPI Number Information
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NPI Number | 1134702111
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Entity Type | Organization
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Legal Business Name | BAY AREA MODERN DENTISTRY LLC
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Dates
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Enumeration Date | 04/28/2021
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Last Update Date | 04/28/2021
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Provider Practice Location Address
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Address Line | 5299 PARK BLVD N
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City | PINELLAS PARK
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State | FL
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Zip | 33781-3418
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Country | US
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Telephone | 727-547-8227
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Fax |
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Provider Business Mailing Address
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Address Line | 506 20TH AVE NE
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City | ST PETERSBURG
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State | FL
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Zip | 33704-4622
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Country | US
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Telephone | 727-686-1808
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | IVO BUSHATI
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Credential | DMD
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Telephone | 727-547-8227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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