Provider Demographics
NPI:1114685740
Name:BANSTOLA
Entity Type:Organization
Organization Name:BANSTOLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BASU
Authorized Official - Middle Name:
Authorized Official - Last Name:BANSTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-934-1698
Mailing Address - Street 1:PO BOX 2635
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30085-2635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2315 BROCKETT RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4412
Practice Address - Country:US
Practice Address - Phone:770-934-1698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental