Provider Demographics
NPI:1942863477
Name:BASTAR, TINA (DDS)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BASTAR
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 1:6148 CORAL PINK CIR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7208
Mailing Address - Country:US
Mailing Address - Phone:949-466-8550
Mailing Address - Fax:
Practice Address - Street 1:19963 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2631
Practice Address - Country:US
Practice Address - Phone:818-703-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1038891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty