Provider Demographics
NPI:1609974997
Name:BISTA, BANDANA (DDS)
Entity Type:Individual
Prefix:
First Name:BANDANA
Middle Name:
Last Name:BISTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 BROOKES WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:TX
Mailing Address - Zip Code:75462-6025
Mailing Address - Country:US
Mailing Address - Phone:646-645-0761
Mailing Address - Fax:
Practice Address - Street 1:4520 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75462-5119
Practice Address - Country:US
Practice Address - Phone:903-737-8543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035779122300000X
TX30180122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist