Provider Demographics
NPI:1053432849
Name:BASTULLI, ANTHONY P (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:P
Last Name:BASTULLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 MAYFIELD RD
Mailing Address - Street 2:#543
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2270
Mailing Address - Country:US
Mailing Address - Phone:440-605-0456
Mailing Address - Fax:
Practice Address - Street 1:6801 MAYFIELD RD
Practice Address - Street 2:#543
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2270
Practice Address - Country:US
Practice Address - Phone:440-605-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH181921223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics