Provider Demographics
NPI:1376817676
Name:BAKAIAN, JUSTIN (RD, CNSC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BAKAIAN
Suffix:
Gender:M
Credentials:RD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04259-7033
Mailing Address - Country:US
Mailing Address - Phone:207-620-2179
Mailing Address - Fax:207-753-7234
Practice Address - Street 1:420 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2104
Practice Address - Country:US
Practice Address - Phone:207-369-1296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1080133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic