Provider Demographics
NPI:1780944629
Name:BASISTA, MICHAEL JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:BASISTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 WINKLER AVE.
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9266
Mailing Address - Country:US
Mailing Address - Phone:239-936-3866
Mailing Address - Fax:239-939-5098
Practice Address - Street 1:2454 WINKLER AVE.
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9266
Practice Address - Country:US
Practice Address - Phone:239-936-3866
Practice Address - Fax:239-939-5098
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6721122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist