Provider Demographics
NPI:1720165756
Name:BAUSBACK, DEBRA GRACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:GRACE
Last Name:BAUSBACK
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 1:840 KENWOOD AVE
Mailing Address - Street 2:P.O. BOX 189
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-9668
Mailing Address - Country:US
Mailing Address - Phone:518-439-9939
Mailing Address - Fax:
Practice Address - Street 1:840 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9668
Practice Address - Country:US
Practice Address - Phone:518-439-9939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045331-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist