Provider Demographics
NPI:1487883559
Name:ELBASTY PEDIATRIC AN DENTA ASSOC.
Entity type:Organization
Organization Name:ELBASTY PEDIATRIC AN DENTA ASSOC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELBASTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:732-615-0700
Mailing Address - Street 1:100 COMMONS WAY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 COMMONS WAY
Practice Address - Street 2:SUITE 130
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733
Practice Address - Country:US
Practice Address - Phone:732-615-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ19874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023035Medicaid
NJ078568Medicare UPIN