Provider Demographics
NPI:1972114056
Name:BANA, BAKHTIAR SADRUDDIN (DDS)
Entity Type:Individual
Prefix:
First Name:BAKHTIAR
Middle Name:SADRUDDIN
Last Name:BANA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11009 ALTERRA PKWY APT 1711
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-1309
Mailing Address - Country:US
Mailing Address - Phone:832-876-5730
Mailing Address - Fax:
Practice Address - Street 1:1110 W WILLIAM CANNON DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5468
Practice Address - Country:US
Practice Address - Phone:512-445-5812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36544122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist