Provider Demographics
NPI:1689693087
Name:BAST, BRIAN T (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:BAST
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 DIVISADERO ST
Mailing Address - Street 2:SUITE 625, BOX 1821
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:415-476-4029
Mailing Address - Fax:415-476-4150
Practice Address - Street 1:513 PARNASSUS AVE RM S738
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2205
Practice Address - Country:US
Practice Address - Phone:415-476-3242
Practice Address - Fax:415-476-0665
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA770231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A770230Medicaid
CA00A770230Medicare PIN
CA00A770230Medicaid