Provider Demographics
NPI:1225369705
Name:LESLIE WELLS DMD, PLLC
Entity Type:Organization
Organization Name:LESLIE WELLS DMD, PLLC
Other - Org Name:NEW AUGUSTA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-964-8400
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:NEW AUGUSTA
Mailing Address - State:MS
Mailing Address - Zip Code:39462-0411
Mailing Address - Country:US
Mailing Address - Phone:601-964-8400
Mailing Address - Fax:601-964-8404
Practice Address - Street 1:203 PINE STREET WEST
Practice Address - Street 2:
Practice Address - City:NEW AUGUSTA
Practice Address - State:MS
Practice Address - Zip Code:39462-0411
Practice Address - Country:US
Practice Address - Phone:601-964-8400
Practice Address - Fax:601-964-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3432071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05838340Medicaid