=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205819083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAMED A ELBASTY DDS, MS, PHDC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2005
-----------------------------------------------------
Last Update Date | 03/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 COMMONS WAY STE 130
-----------------------------------------------------
City | HOLMDEL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-615-0700
-----------------------------------------------------
Fax | 732-615-9152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 COMMONS WAY STE 130
-----------------------------------------------------
City | HOLMDEL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-615-0700
-----------------------------------------------------
Fax | 732-615-9152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 036877
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI01987400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------