Provider Demographics
NPI:1720100837
Name:BASS, LEON (DMD)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18622 AVON RD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5823
Mailing Address - Country:US
Mailing Address - Phone:917-892-3628
Mailing Address - Fax:
Practice Address - Street 1:18622 AVON RD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5823
Practice Address - Country:US
Practice Address - Phone:917-892-3628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist