Provider Demographics
NPI:1578455259
Name:BASTA, MARTINA (DDS)
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:BASTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 CASE RD BLDG C
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-5552
Mailing Address - Country:US
Mailing Address - Phone:951-345-4386
Mailing Address - Fax:
Practice Address - Street 1:3150 CASE RD BLDG C
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-5552
Practice Address - Country:US
Practice Address - Phone:951-345-4386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1116131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice