Provider Demographics
NPI:1245355312
Name:DAVID C BASTACKY DMD PA
Entity type:Organization
Organization Name:DAVID C BASTACKY DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTACKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:410-744-4222
Mailing Address - Street 1:516 N ROLLING RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4140
Mailing Address - Country:US
Mailing Address - Phone:410-744-4222
Mailing Address - Fax:410-744-2472
Practice Address - Street 1:516 N ROLLING RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4140
Practice Address - Country:US
Practice Address - Phone:410-744-4222
Practice Address - Fax:410-744-2472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN930 62930OtherCAREFIRST
MDS164OtherDENTAL NETWORK
MD795229OtherUNITED CONCORDIA
MD2038621OtherAETNA MEDICAL HMO
MD42602402OtherBLUE CROSS
MD210589OtherMDIPA
MD3822OtherFED MED
MD168250000OtherPHN
MD4141305OtherAETNA DENTAL
MD2715OtherDHA FORTIS
MD93918-1OtherDENTAL BENEFIT PROVIDERS
MD795229OtherUNITED CONCORDIA
MD2038621OtherAETNA MEDICAL HMO
MD210589OtherMDIPA