Provider Demographics
NPI:1821147737
Name:KOUJAN BASHA, SAMAR (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMAR
Middle Name:
Last Name:KOUJAN BASHA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 MAPLERIDGE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43455 SCHOENHERR RD STE 1
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1973
Practice Address - Country:US
Practice Address - Phone:586-323-1100
Practice Address - Fax:586-323-1141
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019207122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist