Provider Demographics
NPI:1245488600
Name:BASAWARAJ, SUJATA (DMD)
Entity type:Individual
Prefix:DR
First Name:SUJATA
Middle Name:
Last Name:BASAWARAJ
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 1:4679 SH 121
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4010
Mailing Address - Country:US
Mailing Address - Phone:972-370-1200
Mailing Address - Fax:972-370-2679
Practice Address - Street 1:4679 SH 121
Practice Address - Street 2:SUITE 109
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-4010
Practice Address - Country:US
Practice Address - Phone:972-370-1200
Practice Address - Fax:972-370-2679
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice