MEDICARE: JESSE HUGH MASSIE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1492	WY

General Provider Information

NPI Number	:	1740774454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE HUGH MASSIE DDS

Provider Business Mailing Address
First Line	:	5505 FRANKLIN DR
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-1120
Country	:	US
Telephone Number	:	307-630-0223
Fax Number	:

Provider Business Practice Location Address
First Line	:	7010 YELLOWTAIL RD STE 100
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-6113
Country	:	US
Telephone Number	:	307-632-6597
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	06/15/2018

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