Provider Demographics
NPI:1013427921
Name:UPPER ARLINGTON - BRYAN BASOM DDS LLC
Entity type:Organization
Organization Name:UPPER ARLINGTON - BRYAN BASOM DDS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-406-7187
Mailing Address - Street 1:7870 OLENTANGY RIVER RD STE 205
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1319
Mailing Address - Country:US
Mailing Address - Phone:614-436-0316
Mailing Address - Fax:
Practice Address - Street 1:1840 ZOLLINGER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2850
Practice Address - Country:US
Practice Address - Phone:614-457-3927
Practice Address - Fax:614-457-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.022613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty