Provider Demographics
NPI:1306486840
Name:BASS & KAMP SOUTH MAIN LLC
Entity type:Organization
Organization Name:BASS & KAMP SOUTH MAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:TEBBENKAMP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-838-5050
Mailing Address - Street 1:210 PROFESSIONAL PARK DR SE STE 11
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 PROFESSIONAL PARK DR SE STE 11
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6649
Practice Address - Country:US
Practice Address - Phone:540-951-3989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental