Provider Demographics
NPI:1366645483
Name:BASTKOWSKI, RAYMOND JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JOHN
Last Name:BASTKOWSKI
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 1:4 THRUSH DR
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-2726
Mailing Address - Country:US
Mailing Address - Phone:732-257-3510
Mailing Address - Fax:732-257-3510
Practice Address - Street 1:4 THRUSH DR
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2726
Practice Address - Country:US
Practice Address - Phone:732-257-3510
Practice Address - Fax:732-257-3510
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD10075191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice