Provider Demographics
NPI:1700145349
Name:DDSDMD, LLC
Entity Type:Organization
Organization Name:DDSDMD, LLC
Other - Org Name:BASTIEN DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JEAN-PIERRE
Authorized Official - Last Name:BASTIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-566-2972
Mailing Address - Street 1:5716 FARNSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-4881
Mailing Address - Country:US
Mailing Address - Phone:850-566-2972
Mailing Address - Fax:850-219-1527
Practice Address - Street 1:2621 MITCHAM DR
Practice Address - Street 2:SUITE #102
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5480
Practice Address - Country:US
Practice Address - Phone:850-425-1300
Practice Address - Fax:850-219-1527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN177861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1619274529OtherNPPES
FL1770782039OtherNPPES