Provider Demographics
NPI:1467141994
Name:BASHA, LAILA
Entity type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:BASHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 MAPLERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-2750
Mailing Address - Country:US
Mailing Address - Phone:248-872-2757
Mailing Address - Fax:
Practice Address - Street 1:211 N LEAVITT RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1124
Practice Address - Country:US
Practice Address - Phone:440-984-3840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016017781223G0001X
390200000X
OH30.0278091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program