Provider Demographics
NPI:1376382978
Name:DE LA BASTIDE, ADAM (DDS)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:DE LA BASTIDE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ADAM
Other - Middle Name:
Other - Last Name:DELABASTIDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2 DURHAM DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5311
Mailing Address - Country:US
Mailing Address - Phone:631-560-7811
Mailing Address - Fax:
Practice Address - Street 1:200 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4235
Practice Address - Country:US
Practice Address - Phone:516-663-2752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program