Provider Demographics
NPI:1205819083
Name:ELBASTY, MOHAMED A (DDS, MS, PHDC)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:A
Last Name:ELBASTY
Suffix:
Gender:M
Credentials:DDS, MS, PHDC
Other - Prefix:
Other - First Name:M
Other - Middle Name:A
Other - Last Name:ELBASTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:100 COMMONS WAY
Mailing Address - Street 2:STE 130
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733
Mailing Address - Country:US
Mailing Address - Phone:732-615-0700
Mailing Address - Fax:732-615-9152
Practice Address - Street 1:100 COMMONS WAY
Practice Address - Street 2:STE 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:732-615-9152
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036877122300000X
NJ22DI01987400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00763373Medicaid
NJ0623035Medicaid