Provider Demographics
NPI:1770655185
Name:BASSHAM, ROBERT WALTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WALTON
Last Name:BASSHAM
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 1:669 ADDISON DRIVE
Mailing Address - Street 2:PO BOX 469
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396
Mailing Address - Country:US
Mailing Address - Phone:870-238-7570
Mailing Address - Fax:870-238-1208
Practice Address - Street 1:669 ADDISON DRIVE
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396
Practice Address - Country:US
Practice Address - Phone:870-238-7570
Practice Address - Fax:870-238-1208
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR872310OtherUNITED CONCORDIA
AR58190OtherAR BC BS