Provider Demographics
NPI:1144290487
Name:BASTIN, JEFFREY KENT (DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KENT
Last Name:BASTIN
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 1:401 N LAKEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1229
Mailing Address - Country:US
Mailing Address - Phone:269-651-1716
Mailing Address - Fax:269-651-1717
Practice Address - Street 1:401 N LAKEVIEW ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1229
Practice Address - Country:US
Practice Address - Phone:269-651-1716
Practice Address - Fax:269-651-1717
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI013588122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1487241Medicaid