=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629470471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BASSETT DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2014
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 S FRANKLIN ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63640-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-756-1236
-----------------------------------------------------
Fax | 573-756-7660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 S FRANKLIN ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63640-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-756-1236
-----------------------------------------------------
Fax | 573-756-7660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | DR. BENJAMIN BASSETT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 573-756-1236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | LC1138006
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------