Provider Demographics
NPI:1235655945
Name:BASQUIAT, WILSON J (RDH)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:J
Last Name:BASQUIAT
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 NW 27TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-2826
Mailing Address - Country:US
Mailing Address - Phone:305-805-1700
Mailing Address - Fax:305-805-1715
Practice Address - Street 1:5607 NW 27TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-2826
Practice Address - Country:US
Practice Address - Phone:305-805-1700
Practice Address - Fax:305-805-1715
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH20849124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022136500Medicaid