Provider Demographics
NPI:1902247182
Name:WORTHINGTON HILLS DENTAL BRYAN BASOM DDS
Entity Type:Organization
Organization Name:WORTHINGTON HILLS DENTAL BRYAN BASOM DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:740-775-8050
Mailing Address - Street 1:7870 OLENTANGY RIVER RD STE 205
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1319
Mailing Address - Country:US
Mailing Address - Phone:740-775-8050
Mailing Address - Fax:740-775-8053
Practice Address - Street 1:7870 OLENTANGY RIVER RD STE 205
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1319
Practice Address - Country:US
Practice Address - Phone:740-775-8050
Practice Address - Fax:740-775-8053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHFB0391615OtherDEA REGISTRATION