MEDICARE: DR. RUSSELL KING BASS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	14604	TX

General Provider Information

NPI Number	:	1134121288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL KING BASS D.D.S.

Provider Business Mailing Address
First Line	:	220 S DENTON TAP RD
Second Line	:	STE 101
City	:	COPPELL
State	:	TX
Zip	:	75019-5098
Country	:	US
Telephone Number	:	972-393-6880
Fax Number	:	972-304-9341

Provider Business Practice Location Address
First Line	:	220 S DENTON TAP RD
Second Line	:	STE 101
City	:	COPPELL
State	:	TX
Zip	:	75019-5098
Country	:	US
Telephone Number	:	972-393-6880
Fax Number	:	972-304-9341

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/08/2007

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