Provider Demographics
NPI:1326492539
Name:BASALI, DORIS
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:
Last Name:BASALI
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 1:13027 ANTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-2202
Mailing Address - Country:US
Mailing Address - Phone:216-926-9204
Mailing Address - Fax:
Practice Address - Street 1:13027 ANTHORNE LN
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-2202
Practice Address - Country:US
Practice Address - Phone:216-926-9204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN281381223E0200X
NY062279122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty