Provider Demographics
NPI:1922854587
Name:BASELIOUS, MERNA MICHEAL
Entity type:Individual
Prefix:DR
First Name:MERNA
Middle Name:MICHEAL
Last Name:BASELIOUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 DOGWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WEST LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03784-1749
Mailing Address - Country:US
Mailing Address - Phone:802-356-9700
Mailing Address - Fax:
Practice Address - Street 1:7554 S US HIGHWAY 1 STE 13
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-1450
Practice Address - Country:US
Practice Address - Phone:772-242-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN30053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist