Healthcare Provider Details

I. General information

NPI: 1891757571
Provider Name (Legal Business Name): JOHN ROBERT BASS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 OTTER CREEK PKWY
LITTLE ROCK AR
72210-5792
US

IV. Provider business mailing address

13500 OTTER CREEK PKWY
LITTLE ROCK AR
72210-5792
US

V. Phone/Fax

Practice location:
  • Phone: 501-455-1766
  • Fax: 501-455-5622
Mailing address:
  • Phone: 501-455-1766
  • Fax: 501-455-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2329
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: