Provider Demographics
NPI:1033229562
Name:DIASTI, ADAM
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:DIASTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 W BOY SCOUT BLVD
Mailing Address - Street 2:SUITE 1100-CREDENTIALING
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2307 S DALE MABRY HWY
Practice Address - Street 2:SUITE C
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6322
Practice Address - Country:US
Practice Address - Phone:813-254-6838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN124901223G0001X
TNDS00000074781223G0001X
VA04011024181223G0001X
GADN0116341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice