Provider Demographics
NPI:1093267585
Name:BASS, JUSTIN KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:KEITH
Last Name:BASS
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 1:119 GREGORY BLVD
Mailing Address - Street 2:#44
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06855
Mailing Address - Country:US
Mailing Address - Phone:203-299-0020
Mailing Address - Fax:
Practice Address - Street 1:119 GREGORY BLVD
Practice Address - Street 2:#44
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06855
Practice Address - Country:US
Practice Address - Phone:203-299-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0077511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics