Provider Demographics
NPI:1841486248
Name:FALLAH, BASMA (DDS)
Entity type:Individual
Prefix:DR
First Name:BASMA
Middle Name:
Last Name:FALLAH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 MATTISON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2623
Mailing Address - Country:US
Mailing Address - Phone:650-248-4069
Mailing Address - Fax:
Practice Address - Street 1:6252 DAVIS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-7422
Practice Address - Country:US
Practice Address - Phone:650-248-4069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX245181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics