Provider Demographics
NPI:1063809820
Name:SAM BASS FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:SAM BASS FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUPA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVINDARAJAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:951-454-2716
Mailing Address - Street 1:2000 SAM BASS RD STE 108
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-2001
Mailing Address - Country:US
Mailing Address - Phone:512-341-3200
Mailing Address - Fax:
Practice Address - Street 1:2000 SAM BASS RD STE 108
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-2001
Practice Address - Country:US
Practice Address - Phone:512-341-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12455101016Medicaid