Provider Demographics
NPI:1215469564
Name:BASTIDA, JASON ALEXANDER (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALEXANDER
Last Name:BASTIDA
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 1:3565 86TH ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5601
Mailing Address - Country:US
Mailing Address - Phone:646-675-9671
Mailing Address - Fax:
Practice Address - Street 1:4014 82ND ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1305
Practice Address - Country:US
Practice Address - Phone:718-397-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0599671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program