Provider Demographics
NPI:1194844944
Name:BASS, DARRELL BENNETT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:BENNETT
Last Name:BASS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 AEROVISTA PL STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8741
Mailing Address - Country:US
Mailing Address - Phone:805-543-4266
Mailing Address - Fax:805-544-3950
Practice Address - Street 1:835 AEROVISTA PL STE 210
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8741
Practice Address - Country:US
Practice Address - Phone:805-543-4266
Practice Address - Fax:805-544-3950
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist