Healthcare Provider Details

I. General information

NPI: 1952480162
Provider Name (Legal Business Name): DENNIS P BASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DRIVE
FAYETTEVILLE NC
28304-3234
US

IV. Provider business mailing address

PO BOX 63213
CHARLOTTE NC
28263-3213
US

V. Phone/Fax

Practice location:
  • Phone: 910-609-4000
  • Fax:
Mailing address:
  • Phone: 800-279-1395
  • Fax: 517-694-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34818
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number34818
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number09725
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number045166
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: