Healthcare Provider Details

I. General information

NPI: 1235655945
Provider Name (Legal Business Name): WILSON J. BASQUIAT RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5607 NW 27TH AVE STE 2
MIAMI FL
33142-2826
US

IV. Provider business mailing address

5607 NW 27TH AVE STE 1
MIAMI FL
33142-2826
US

V. Phone/Fax

Practice location:
  • Phone: 305-805-1700
  • Fax: 305-805-1715
Mailing address:
  • Phone: 305-805-1700
  • Fax: 305-805-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH20849
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: