MEDICARE: DR. ADAM DIASTI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN12490	FL
2	1223G0001X	General Practice Dentistry	DS0000007478	TN
3	1223G0001X	General Practice Dentistry	0401102418	VA
4	1223G0001X	General Practice Dentistry	DN011634	GA

General Provider Information

NPI Number	:	1033229562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADAM DIASTI

Provider Business Mailing Address
First Line	:	4010 W BOY SCOUT BLVD
Second Line	:	SUITE 1100-CREDENTIALING
City	:	TAMPA
State	:	FL
Zip	:	33607-5727
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2307 S DALE MABRY HWY
Second Line	:	SUITE C
City	:	TAMPA
State	:	FL
Zip	:	33629-6322
Country	:	US
Telephone Number	:	813-254-6838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	06/29/2011

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