Healthcare Provider Details

I. General information

NPI: 1245153725
Provider Name (Legal Business Name): BASHAYER MULLA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 12TH ST FL 4
RICHMOND VA
23298-5064
US

IV. Provider business mailing address

5000 LIBBIE MILL EAST BLVD
RICHMOND VA
23230-2157
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-6083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0442000599
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: