Provider Demographics
NPI:1417564618
Name:BASS, KELLI LANETTE (DDS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LANETTE
Last Name:BASS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5134 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-7044
Mailing Address - Country:US
Mailing Address - Phone:210-718-9616
Mailing Address - Fax:
Practice Address - Street 1:1712 N ACCESS RD
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:TX
Practice Address - Zip Code:79510-3352
Practice Address - Country:US
Practice Address - Phone:325-893-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX367251223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health