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General NPI Number Information
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NPI Number | 1700145349
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Entity Type | Organization
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Legal Business Name | DDSDMD, LLC
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Dates
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Enumeration Date | 05/15/2012
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Last Update Date | 05/15/2012
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Provider Practice Location Address
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Address Line | 2621 MITCHAM DR SUITE #102
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City | TALLAHASSEE
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State | FL
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Zip | 32308-5480
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Country | US
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Telephone | 850-425-1300
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Fax | 850-219-1527
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Provider Business Mailing Address
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Address Line | 5716 FARNSWORTH DR
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City | TALLAHASSEE
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State | FL
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Zip | 32312-4881
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Country | US
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Telephone | 850-566-2972
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Fax | 850-219-1527
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD JEAN-PIERRE BASTIEN
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Credential | D.M.D.
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Telephone | 850-566-2972
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN17786
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License Number State | FL
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