Provider Demographics
NPI:1962753996
Name:BASTA, TREVOR (DMD)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:
Last Name:BASTA
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 1:4575 CANYON DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519-7900
Mailing Address - Country:US
Mailing Address - Phone:775-250-3499
Mailing Address - Fax:
Practice Address - Street 1:840 I ST
Practice Address - Street 2:STE 3
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-3677
Practice Address - Country:US
Practice Address - Phone:775-358-1870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV63361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice