Provider Demographics
NPI:1871214338
Name:BASMA, ADAM
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:BASMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6248 VINELAND AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3753
Mailing Address - Country:US
Mailing Address - Phone:818-852-2979
Mailing Address - Fax:
Practice Address - Street 1:44407 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-3237
Practice Address - Country:US
Practice Address - Phone:661-206-3983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107962122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist