Provider Demographics
NPI:1801316435
Name:BASHOURA, MICHAEL (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BASHOURA
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E 13TH ST UNIT 2603
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64106-2954
Mailing Address - Country:US
Mailing Address - Phone:909-450-7615
Mailing Address - Fax:
Practice Address - Street 1:2101 CHARLOTTE ST STE 310
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2727
Practice Address - Country:US
Practice Address - Phone:816-404-4356
Practice Address - Fax:816-404-4356
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-24
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017019368122300000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist