Basic Information
| Provider Information | |||||||||
| NPI: | 1689693087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAST | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 DIVISADERO ST | ||||||||
| Address2: | SUITE 625, BOX 1821 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941430001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154764029 | ||||||||
| FaxNumber: | 4154764150 | ||||||||
| Practice Location | |||||||||
| Address1: | 513 PARNASSUS AVE RM S738 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154763242 | ||||||||
| FaxNumber: | 4154760665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | A77023 | CA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A770230 | 05 | CA | MEDICAID |