Provider Demographics
NPI:1679618326
Name:BASILE ORTHODONTICS PA
Entity type:Organization
Organization Name:BASILE ORTHODONTICS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:BASILE
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-454-5345
Mailing Address - Street 1:5116 GATEWAY ST. S.E.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372
Mailing Address - Country:US
Mailing Address - Phone:952-447-6088
Mailing Address - Fax:952-447-6099
Practice Address - Street 1:5116 GATEWAY STREET SE #103
Practice Address - Street 2:SUITE #103
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372
Practice Address - Country:US
Practice Address - Phone:952-447-6088
Practice Address - Fax:952-447-6099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BASILE ORTHODONTICS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN109831223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty