Provider Demographics
NPI:1871707836
Name:TIMOTHY J. BASHARA, DMD, PLC
Entity type:Organization
Organization Name:TIMOTHY J. BASHARA, DMD, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BASHARA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-988-1879
Mailing Address - Street 1:5656 S. POWER RD.
Mailing Address - Street 2:STE. 118
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295
Mailing Address - Country:US
Mailing Address - Phone:480-988-1879
Mailing Address - Fax:480-988-4690
Practice Address - Street 1:5656 S. POWER RD.
Practice Address - Street 2:STE. 118
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295
Practice Address - Country:US
Practice Address - Phone:480-988-1879
Practice Address - Fax:480-988-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD56881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ718794Medicaid
AZ718794OtherAHCCCS PROVIDER NUMBER
AZ718794Medicaid