MEDICARE: DR. SUJATA BASAWARAJ DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	20290	TX

General Provider Information

NPI Number	:	1245488600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUJATA BASAWARAJ DMD

Provider Business Mailing Address
First Line	:	4679 SH 121
Second Line	:	SUITE 109
City	:	LEWISVILLE
State	:	TX
Zip	:	75056-4010
Country	:	US
Telephone Number	:	972-370-1200
Fax Number	:	972-370-2679

Provider Business Practice Location Address
First Line	:	4679 SH 121
Second Line	:	SUITE 109
City	:	LEWISVILLE
State	:	TX
Zip	:	75056-4010
Country	:	US
Telephone Number	:	972-370-1200
Fax Number	:	972-370-2679

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2008
Last Update Date	:	08/28/2008

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