MEDICARE: NICKIE ROSE BASTANI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901020839	MI
2	1223P0221X	Pediatric Dentistry	2901020839	MI

General Provider Information

NPI Number	:	1801140892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKIE ROSE BASTANI DDS

Provider Business Mailing Address
First Line	:	1363 TATE MODERN LANE
Second Line	:
City	:	GREAT FALLS
State	:	VA
Zip	:	22066
Country	:	US
Telephone Number	:	571-426-8274
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 JOSEPH SIEWICK DR STE 104
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22033-1737
Country	:	US
Telephone Number	:	703-620-9122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2012
Last Update Date	:	01/21/2021

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