Provider Demographics
NPI:1912691288
Name:BASSA, WALEED (DMD)
Entity type:Individual
Prefix:
First Name:WALEED
Middle Name:
Last Name:BASSA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3360 ESPLANADE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-3665
Mailing Address - Country:US
Mailing Address - Phone:409-893-2907
Mailing Address - Fax:
Practice Address - Street 1:8035 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-7021
Practice Address - Country:US
Practice Address - Phone:409-893-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist