Provider Demographics
NPI:1134702111
Name:BAY AREA MODERN DENTISTRY LLC
Entity Type:Organization
Organization Name:BAY AREA MODERN DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:IVO
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSHATI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-547-8227
Mailing Address - Street 1:506 20TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-4622
Mailing Address - Country:US
Mailing Address - Phone:727-686-1808
Mailing Address - Fax:
Practice Address - Street 1:5299 PARK BLVD N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3418
Practice Address - Country:US
Practice Address - Phone:727-547-8227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty