Provider Demographics
NPI:1093450769
Name:BASORE, MAKENNA PAIGE (DMD)
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:PAIGE
Last Name:BASORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 DIVISION RD APT 202
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-1984
Mailing Address - Country:US
Mailing Address - Phone:740-262-1720
Mailing Address - Fax:
Practice Address - Street 1:7300 N PERIMETER RD
Practice Address - Street 2:
Practice Address - City:MALMSTROM AFB
Practice Address - State:MT
Practice Address - Zip Code:59402-6701
Practice Address - Country:US
Practice Address - Phone:406-731-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.026870122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program