Provider Demographics
NPI:1770133340
Name:BASHA, GABRIELLA C (DMD)
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:C
Last Name:BASHA
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 1:9002 LUPINE DEN DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2163
Mailing Address - Country:US
Mailing Address - Phone:202-468-1641
Mailing Address - Fax:
Practice Address - Street 1:131 ELDEN ST STE 130
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4835
Practice Address - Country:US
Practice Address - Phone:703-689-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014167211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice