Provider Demographics
NPI:1376565721
Name:BASCO, MARIE JANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:JANE
Last Name:BASCO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:BASCO
Other - Last Name:VAN VLERIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2771 MONUMENT RD STE 21
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3514
Mailing Address - Country:US
Mailing Address - Phone:904-641-3732
Mailing Address - Fax:904-641-0225
Practice Address - Street 1:2771 MONUMENT RD STE 21
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-3514
Practice Address - Country:US
Practice Address - Phone:904-641-3732
Practice Address - Fax:904-641-0225
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist