Provider Demographics
NPI:1851704555
Name:BASTAWROS, AMY (DMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BASTAWROS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 MARLBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2157
Mailing Address - Country:US
Mailing Address - Phone:617-266-0441
Mailing Address - Fax:
Practice Address - Street 1:26 MARLBOROUGH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2157
Practice Address - Country:US
Practice Address - Phone:617-266-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856816122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program