Provider Demographics
NPI:1790414654
Name:BASS, WILLIE D
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:D
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14275 MIDWAY RD STE 260
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3613
Mailing Address - Country:US
Mailing Address - Phone:214-783-4302
Mailing Address - Fax:
Practice Address - Street 1:14275 MIDWAY RD STE 260
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3613
Practice Address - Country:US
Practice Address - Phone:702-900-4522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program