Provider Demographics
NPI:1144515800
Name:BASS, DIANA S (DDS)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:BASS
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 1:219B WILMOT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4048
Mailing Address - Country:US
Mailing Address - Phone:704-864-9949
Mailing Address - Fax:704-864-5954
Practice Address - Street 1:219B WILMOT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4048
Practice Address - Country:US
Practice Address - Phone:704-864-9949
Practice Address - Fax:704-864-5954
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC91061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice