Healthcare Provider Details

I. General information

NPI: 1003475161
Provider Name (Legal Business Name): CAROLINE W. L. BASTA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4063 N GOLDENROD RD STE 4
WINTER PARK FL
32792-8905
US

IV. Provider business mailing address

2044 WOOD THRUSH LN
WINTER PARK FL
32792-3164
US

V. Phone/Fax

Practice location:
  • Phone: 407-677-8888
  • Fax:
Mailing address:
  • Phone: 702-601-4714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number24833
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7192
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24833
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: