Provider Demographics
NPI:1386842979
Name:BISTRAIN, ANTONIO M (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:M
Last Name:BISTRAIN
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 1:2426 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2016
Mailing Address - Country:US
Mailing Address - Phone:510-845-3510
Mailing Address - Fax:510-845-3900
Practice Address - Street 1:2426 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2016
Practice Address - Country:US
Practice Address - Phone:510-845-3510
Practice Address - Fax:510-845-3900
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice