Provider Demographics
NPI:1174185268
Name:BASTA, MELODY NIGHTINGALE (DDS)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:NIGHTINGALE
Last Name:BASTA
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 1:7831 SOUTHFORK BND
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4882
Mailing Address - Country:US
Mailing Address - Phone:409-543-3603
Mailing Address - Fax:
Practice Address - Street 1:5800 N TARRANT PKWY STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8003
Practice Address - Country:US
Practice Address - Phone:817-581-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX351601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice