Basic Information
| Provider Information | |||||||||
| NPI: | 1235257684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASSABNY | ||||||||
| FirstName: | BASSAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 275 HOBART ST | ||||||||
| Address2: | |||||||||
| City: | PERTH AMBOY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088613396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323769333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 275 HOBART STREET | ||||||||
| Address2: | |||||||||
| City: | PERTH AMBOY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323769333 | ||||||||
| FaxNumber: | 7323245765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 22DI02129600 | NJ | N | Dental Providers | Dentist | General Practice | 1223G0001X | 21296 | NJ | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0381080 | 05 | NJ | MEDICAID |