Provider Demographics
NPI:1770669020
Name:BASS, ROGER KYLE (DMD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:KYLE
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 1:103 SOUTH FIR AVE.
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:MS
Mailing Address - Zip Code:39428
Mailing Address - Country:US
Mailing Address - Phone:601-765-4355
Mailing Address - Fax:601-765-4745
Practice Address - Street 1:103 SOUTH FIR AVE.
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428
Practice Address - Country:US
Practice Address - Phone:601-765-4355
Practice Address - Fax:601-765-4745
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS32871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02880272Medicaid