Provider Demographics
NPI:1144610916
Name:DESTA, DAVID
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:DESTA
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 1:9600 BLACKWELL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3670
Mailing Address - Country:US
Mailing Address - Phone:617-840-4323
Mailing Address - Fax:
Practice Address - Street 1:9600 BLACKWELL RD STE 103
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3670
Practice Address - Country:US
Practice Address - Phone:178-404-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD157051223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty