Provider Demographics
NPI:1780700203
Name:BASSE, LESLIE REENE (DDS)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:REENE
Last Name:BASSE
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 1:517 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-3046
Mailing Address - Country:US
Mailing Address - Phone:307-864-2653
Mailing Address - Fax:
Practice Address - Street 1:209 S 7TH ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3307
Practice Address - Country:US
Practice Address - Phone:307-347-2544
Practice Address - Fax:307-347-2352
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY301685OtherBLUE CROSS BLUE SHIELD