Provider Demographics
NPI:1962684696
Name:BASSILLEANN P.A.
Entity Type:Organization
Organization Name:BASSILLEANN P.A.
Other - Org Name:CLEARWATER FAMILY AND SEDATION DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-558-6810
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55320-0187
Mailing Address - Country:US
Mailing Address - Phone:320-558-6810
Mailing Address - Fax:320-558-6006
Practice Address - Street 1:505 N. WALNUT STREET
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:MN
Practice Address - Zip Code:55320
Practice Address - Country:US
Practice Address - Phone:320-558-6810
Practice Address - Fax:320-558-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty