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General NPI Number Information
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NPI Number | 1679618326
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Entity Type | Organization
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Legal Business Name | BASILE ORTHODONTICS PA
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 02/17/2009
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Provider Practice Location Address
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Address Line | 5116 GATEWAY STREET SE #103 SUITE #103
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City | PRIOR LAKE
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State | MN
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Zip | 55372
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Country | US
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Telephone | 952-447-6088
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Fax | 952-447-6099
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Provider Business Mailing Address
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Address Line | 5116 GATEWAY ST. S.E. SUITE 103
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City | PRIOR LAKE
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State | MN
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Zip | 55372
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Country | US
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Telephone | 952-447-6088
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Fax | 952-447-6099
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. JOSEPH SAMUEL BASILE III
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Credential | D.D.S.
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Telephone | 952-454-5345
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | MN10983
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License Number State | MN
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