Provider Demographics
NPI:1790786077
Name:BASHAM, LAURENCE ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:ANTHONY
Last Name:BASHAM
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 1:5180 WALNUT PARK
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93111
Mailing Address - Country:US
Mailing Address - Phone:805-680-9572
Mailing Address - Fax:805-967-8997
Practice Address - Street 1:122 S PATTERSON AVE. #107
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93111
Practice Address - Country:US
Practice Address - Phone:805-967-0272
Practice Address - Fax:805-967-8997
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22778122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22620926OtherEMPLOYER NUMBER