Provider Demographics
NPI:1003086174
Name:A.T. BASSIRI, D.D.S., P.A.
Entity Type:Organization
Organization Name:A.T. BASSIRI, D.D.S., P.A.
Other - Org Name:PINE VALLEY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:TOI
Authorized Official - Last Name:INMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-425-2273
Mailing Address - Street 1:1661 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3425
Mailing Address - Country:US
Mailing Address - Phone:910-485-2273
Mailing Address - Fax:910-485-0772
Practice Address - Street 1:1661 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-485-2273
Practice Address - Fax:910-485-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC767829OtherUNITED CONCORDIA
NC90477OtherBLUE CROSS OF NC
NC8990477Medicaid