Healthcare Provider Details

I. General information

NPI: 1417918947
Provider Name (Legal Business Name): BENJAMIN A BASSICHIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14755 PRESTON RD SUITE 110
DALLAS TX
75254-6815
US

IV. Provider business mailing address

14755 PRESTON RD SUITE 110
DALLAS TX
75254-6815
US

V. Phone/Fax

Practice location:
  • Phone: 972-774-1777
  • Fax:
Mailing address:
  • Phone: 972-774-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberK2643
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: