Healthcare Provider Details

I. General information

NPI: 1013427921
Provider Name (Legal Business Name): UPPER ARLINGTON - BRYAN BASOM DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 ZOLLINGER RD
COLUMBUS OH
43221-2850
US

IV. Provider business mailing address

7870 OLENTANGY RIVER RD STE 205
COLUMBUS OH
43235-1319
US

V. Phone/Fax

Practice location:
  • Phone: 614-457-3927
  • Fax: 614-457-0668
Mailing address:
  • Phone: 614-436-0316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.022613
License Number StateOH

VIII. Authorized Official

Name: DR. BRYAN BASOM
Title or Position: OWNER
Credential: DDS
Phone: 614-406-7187