Healthcare Provider Details

I. General information

NPI: 1548092430
Provider Name (Legal Business Name): DALLIN BASSETT OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N MAIN AVE
AZTEC NM
87410-1923
US

IV. Provider business mailing address

4916 KINGSWAY DR
FARMINGTON NM
87402-4861
US

V. Phone/Fax

Practice location:
  • Phone: 505-333-7278
  • Fax:
Mailing address:
  • Phone: 832-613-1096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DALLIN BASSETT
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 832-613-1096