MEDICARE: DR. JAY MARSHALL BASS DDS

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	1223G0001X	General Practice Dentistry	0401412144	VA

General Provider Information

NPI Number	:	1295996411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY MARSHALL BASS DDS

Provider Business Mailing Address
First Line	:	200 WASHINGTON ST SE
Second Line	:
City	:	BLACKSBURG
State	:	VA
Zip	:	24060-4838
Country	:	US
Telephone Number	:	540-552-2551
Fax Number	:	540-961-9864

Provider Business Practice Location Address
First Line	:	200 WASHINGTON ST SE
Second Line	:
City	:	BLACKSBURG
State	:	VA
Zip	:	24060-4838
Country	:	US
Telephone Number	:	540-552-2551
Fax Number	:	540-961-9864

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

Provider Enumeration Date	:	06/19/2008
Last Update Date	:	06/19/2008

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