Healthcare Provider Details

I. General information

NPI: 1457186876
Provider Name (Legal Business Name): GUMCARE AND IMPLANT SPECIALISTS LLC - DR. BASTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 EXECUTIVE CIR NW # A
CANTON OH
44718-2983
US

IV. Provider business mailing address

4410 EXECUTIVE CIR NW # A
CANTON OH
44718-2983
US

V. Phone/Fax

Practice location:
  • Phone: 330-349-7004
  • Fax:
Mailing address:
  • Phone: 330-349-7004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. KARIM BASTA
Title or Position: OWNER
Credential:
Phone: 330-494-7004