Provider Demographics
NPI:1073679742
Name:BASTIAN, JOHN STAFFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STAFFORD
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2609
Mailing Address - Country:US
Mailing Address - Phone:615-824-6804
Mailing Address - Fax:615-264-3607
Practice Address - Street 1:734 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2609
Practice Address - Country:US
Practice Address - Phone:615-824-6804
Practice Address - Fax:615-264-3607
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS3874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist