Provider Demographics
NPI:1053447458
Name:BASILE, MARTHA K (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:K
Last Name:BASILE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-3107
Mailing Address - Country:US
Mailing Address - Phone:815-568-1202
Mailing Address - Fax:
Practice Address - Street 1:110 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-3107
Practice Address - Country:US
Practice Address - Phone:815-568-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist