Basic Information
| Provider Information | |||||||||
| NPI: | 1417564618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | LANETTE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5134 SPRING CREEK RD | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796027044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107189616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1712 N ACCESS RD | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795103352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3258934010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 36725 | TX | N | Dental Providers | Dentist | Dental Public Health | 1223G0001X | 36725 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.