Provider Demographics
NPI:1952310138
Name:BASS, BRETT ALAN (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:ALAN
Last Name:BASS
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 MILL BAY RD
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6411
Mailing Address - Country:US
Mailing Address - Phone:907-486-3291
Mailing Address - Fax:907-486-3015
Practice Address - Street 1:1317 MILL BAY RD
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6411
Practice Address - Country:US
Practice Address - Phone:907-486-3291
Practice Address - Fax:907-486-3015
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120094511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK886257OtherUCCI PROVIDER NUMBER
AKDD02941Medicaid