Provider Demographics
NPI:1922473057
Name:BASIAGA, JODI (RDH)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:
Last Name:BASIAGA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2843 VISTAVIEW DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8204
Mailing Address - Country:US
Mailing Address - Phone:616-328-7409
Mailing Address - Fax:
Practice Address - Street 1:2843 VISTAVIEW DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8204
Practice Address - Country:US
Practice Address - Phone:616-328-7409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902012957124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist