Provider Demographics
NPI:1609233402
Name:DAVID BASTIANELLI, DDS, PLLC
Entity Type:Organization
Organization Name:DAVID BASTIANELLI, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-644-6688
Mailing Address - Street 1:522 E LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1791
Mailing Address - Country:US
Mailing Address - Phone:248-644-6688
Mailing Address - Fax:248-644-3470
Practice Address - Street 1:522 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-1791
Practice Address - Country:US
Practice Address - Phone:248-644-6688
Practice Address - Fax:248-644-3470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1354701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty