Provider Demographics
NPI:1902248412
Name:ADEINAT, BASHAR
Entity Type:Individual
Prefix:
First Name:BASHAR
Middle Name:
Last Name:ADEINAT
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 1:4673 SW 75TH WAY
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-4113
Mailing Address - Country:US
Mailing Address - Phone:860-218-5560
Mailing Address - Fax:
Practice Address - Street 1:1340 BLANDING BLVD STE 108
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065
Practice Address - Country:US
Practice Address - Phone:904-639-6924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN223031223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program