Provider Demographics
NPI:1073888152
Name:BASHA, MARIANA
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:BASHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18506 HAWTHORNE BLVD.
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-4515
Mailing Address - Country:US
Mailing Address - Phone:310-483-7779
Mailing Address - Fax:844-812-0727
Practice Address - Street 1:18506 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90504-4515
Practice Address - Country:US
Practice Address - Phone:310-483-7779
Practice Address - Fax:844-812-0727
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist