Provider Demographics
NPI:1487871653
Name:BASARICH, DANIEL GEORGE (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:GEORGE
Last Name:BASARICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:175 E MILL STREET
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581
Mailing Address - Country:US
Mailing Address - Phone:608-647-6222
Mailing Address - Fax:
Practice Address - Street 1:175 E MILL STREET
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581
Practice Address - Country:US
Practice Address - Phone:608-647-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33563400Medicaid