Healthcare Provider Details

I. General information

NPI: 1780763300
Provider Name (Legal Business Name): JAIRO BASTIDAS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

90 PALISADE AVE
WHITE PLAINS NY
10607-2725
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4167
  • Fax: 718-515-5419
Mailing address:
  • Phone: 718-920-4167
  • Fax: 718-515-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number041328
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: