Provider Demographics
NPI:1619369972
Name:BASS, DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:140 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1040
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:670 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-2021
Practice Address - Country:US
Practice Address - Phone:541-447-3855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10997122300000X
WARR60482579122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist