Provider Demographics
NPI:1164429387
Name:BASTACKY, DAVID C (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:BASTACKY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:516 N ROLLING RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4140
Mailing Address - Country:US
Mailing Address - Phone:410-744-4222
Mailing Address - Fax:410-744-2472
Practice Address - Street 1:516 N ROLLING RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4140
Practice Address - Country:US
Practice Address - Phone:410-744-4222
Practice Address - Fax:410-744-2472
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD10337204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDT92830Medicare UPIN
MDK446X946Medicare PIN