Provider Demographics
NPI:1932805066
Name:BASSALY, MINA (DMD)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:BASSALY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 STANTON CIR
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-1905
Mailing Address - Country:US
Mailing Address - Phone:727-637-5231
Mailing Address - Fax:
Practice Address - Street 1:10 STANTON CIR
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-1905
Practice Address - Country:US
Practice Address - Phone:727-637-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X
FL282021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health