Provider Demographics
NPI:1750149381
Name:BASTANI, PEYMAN (DMD)
Entity type:Individual
Prefix:
First Name:PEYMAN
Middle Name:
Last Name:BASTANI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CHILPANCINGO PKWY APT 3205
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1376
Mailing Address - Country:US
Mailing Address - Phone:925-852-4641
Mailing Address - Fax:
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 290
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2353
Practice Address - Country:US
Practice Address - Phone:702-774-5134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV8042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program