Provider Demographics
NPI:1780721621
Name:BASHAWATY, WALLY (DDS)
Entity type:Individual
Prefix:
First Name:WALLY
Middle Name:
Last Name:BASHAWATY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SUPERIOR AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3641
Mailing Address - Country:US
Mailing Address - Phone:949-645-8222
Mailing Address - Fax:949-645-3111
Practice Address - Street 1:1501 SUPERIOR AVE STE 306
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3641
Practice Address - Country:US
Practice Address - Phone:949-645-8222
Practice Address - Fax:949-645-3111
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45429122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA831034OtherUNITED CONCORDIA PROVIDER