Provider Demographics
NPI:1922510197
Name:BASSILY, OLIVIA MARINA (DMD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MARINA
Last Name:BASSILY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 113TH ST
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-2800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9200 113TH ST
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-2800
Practice Address - Country:US
Practice Address - Phone:727-394-6213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-28
Last Update Date:2017-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice