Provider Demographics
NPI:1912118118
Name:ANTIC GROEN, BAS MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BAS
Middle Name:MICHAEL
Last Name:ANTIC GROEN
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:PO BOX 70341
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33307-0341
Mailing Address - Country:US
Mailing Address - Phone:310-569-2651
Mailing Address - Fax:
Practice Address - Street 1:100 S MILITARY TRL
Practice Address - Street 2:SUITE 4
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-3032
Practice Address - Country:US
Practice Address - Phone:954-725-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN178521223E0200X
CA554731223E0200X
AZD67091223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics