Provider Demographics
NPI:1538478573
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:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARASH
Authorized Official - Middle Name:T
Authorized Official - Last Name:BASSIRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:910-867-2344
Mailing Address - Street 1:7766 GOOD MIDDLING DRIVE
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:910-867-2344
Mailing Address - Fax:910-826-0028
Practice Address - Street 1:7766 GOOD MIDDLING DRIVE
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:910-867-2344
Practice Address - Fax:910-826-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC63151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990477Medicaid