Provider Demographics
NPI:1093252611
Name:BASTROP MODERN DENTISTRY,PC
Entity Type:Organization
Organization Name:BASTROP MODERN DENTISTRY,PC
Other - Org Name:BASTROP MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-240-6496
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:
Practice Address - Street 1:1670 HWY 71 E, SUITE A
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602
Practice Address - Country:US
Practice Address - Phone:512-240-6496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty