Provider Demographics
NPI:1740774454
Name:MASSIE, JESSE HUGH (DDS)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:HUGH
Last Name:MASSIE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 FRANKLIN DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-1120
Mailing Address - Country:US
Mailing Address - Phone:307-630-0223
Mailing Address - Fax:
Practice Address - Street 1:7010 YELLOWTAIL RD STE 100
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-6113
Practice Address - Country:US
Practice Address - Phone:307-632-6597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice