Provider Demographics
NPI:1942835574
Name:BASULTO, LOURDES (DA)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:BASULTO
Suffix:
Gender:F
Credentials:DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 W 16TH AVE STE 52
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7193
Mailing Address - Country:US
Mailing Address - Phone:305-825-9899
Mailing Address - Fax:
Practice Address - Street 1:4410 W 16TH AVE STE 52
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7193
Practice Address - Country:US
Practice Address - Phone:305-825-9899
Practice Address - Fax:305-825-9858
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDR134398126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental AssistantGroup - Single Specialty