Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 10337 | MD |
NPI | 1164429387 |
---|---|
Provider Name | Dr. David C Bastacky |
First Address | Baltimore, MD 21228-4140 |
Second Address | Baltimore, MD 21228-4140 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2005 |
Last Update Date | 02/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T92830 | (02) | MD |