Healthcare Provider Details

I. General information

NPI: 1518453059
Provider Name (Legal Business Name): BASMAN KRAIDI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7165 PEACH ST
ERIE PA
16509-4764
US

IV. Provider business mailing address

2258 LAKEVIEW DR
ERIE PA
16506-6401
US

V. Phone/Fax

Practice location:
  • Phone: 814-864-1500
  • Fax:
Mailing address:
  • Phone: 619-277-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600407
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS041818
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: