Provider Demographics
NPI:1578600326
Name:BASIN, SERGEY YEVGENYEVICH (DDS)
Entity Type:Individual
Prefix:DR
First Name:SERGEY
Middle Name:YEVGENYEVICH
Last Name:BASIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2806
Mailing Address - Country:US
Mailing Address - Phone:908-354-1500
Mailing Address - Fax:
Practice Address - Street 1:707 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2806
Practice Address - Country:US
Practice Address - Phone:908-354-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0520951223G0001X
NJ22DI022921001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02664973Medicaid
NJ0150258Medicaid