Healthcare Provider Details

I. General information

NPI: 1790786077
Provider Name (Legal Business Name): LAURENCE ANTHONY BASHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S PATTERSON AVE. #107
SANTA BARBARA CA
93111
US

IV. Provider business mailing address

5180 WALNUT PARK
SANTA BARBARA CA
93111
US

V. Phone/Fax

Practice location:
  • Phone: 805-967-0272
  • Fax: 805-967-8997
Mailing address:
  • Phone: 805-680-9572
  • Fax: 805-967-8997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22778
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22778
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: