Provider Demographics
NPI:1710472980
Name:BASHA, VINCENT
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:BASHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BEACH ST APT 906
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1613
Mailing Address - Country:US
Mailing Address - Phone:857-333-5481
Mailing Address - Fax:
Practice Address - Street 1:31 BEACH ST APT 906
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1613
Practice Address - Country:US
Practice Address - Phone:857-333-5481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF117651223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics