Healthcare Provider Details

I. General information

NPI: 1912104399
Provider Name (Legal Business Name): BASSEL GEBRAEL D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3146B NORTHSIDE DRIVE
KEY WEST FL
33040
US

IV. Provider business mailing address

1830 SOUTH OCEAN DRIVE #4303
HALLANDALE BEACH FL
33009-7716
US

V. Phone/Fax

Practice location:
  • Phone: 305-294-4661
  • Fax:
Mailing address:
  • Phone: 954-815-8040
  • Fax: 954-456-2797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN15557
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: