Provider Demographics
NPI:1003475161
Name:BASTA, CAROLINE W L (DDS)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:W L
Last Name:BASTA
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 1:2044 WOOD THRUSH LN
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3164
Mailing Address - Country:US
Mailing Address - Phone:702-601-4714
Mailing Address - Fax:
Practice Address - Street 1:4063 N GOLDENROD RD STE 4
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-8905
Practice Address - Country:US
Practice Address - Phone:407-677-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24833122300000X
NV7192122300000X
FLDN24833122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist