Provider Demographics
NPI:1326387341
Name:DESTINE, EDLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDLY
Middle Name:
Last Name:DESTINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 W LINCOLN AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-1181
Mailing Address - Country:US
Mailing Address - Phone:914-699-6988
Mailing Address - Fax:
Practice Address - Street 1:88 W LINCOLN AVE STE 102
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-1181
Practice Address - Country:US
Practice Address - Phone:146-996-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0574731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04140667Medicaid