Provider Demographics
NPI:1962788091
Name:BASTOS, ISABEL (DMD)
Entity type:Individual
Prefix:MRS
First Name:ISABEL
Middle Name:
Last Name:BASTOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740
Mailing Address - Country:US
Mailing Address - Phone:732-391-2824
Mailing Address - Fax:732-222-2700
Practice Address - Street 1:335 BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6901
Practice Address - Country:US
Practice Address - Phone:732-475-3800
Practice Address - Fax:732-483-6444
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02485500122300000X
NJ22DI02485500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0279463Medicaid