Healthcare Provider Details

I. General information

NPI: 1225369705
Provider Name (Legal Business Name): LESLIE WELLS DMD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 PINE STREET WEST
NEW AUGUSTA MS
39462-0411
US

IV. Provider business mailing address

PO BOX 411
NEW AUGUSTA MS
39462-0411
US

V. Phone/Fax

Practice location:
  • Phone: 601-964-8400
  • Fax: 601-964-8400
Mailing address:
  • Phone: 601-964-8400
  • Fax: 601-964-8404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number343207
License Number StateMS

VIII. Authorized Official

Name: DR. LESLIE RAE WELLS
Title or Position: OWNER
Credential: DMD
Phone: 601-964-8400