MEDICARE: DR. PHILIP JULIUS WELLS D.D.S.

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	122300000X	Dentist	16267	OH

General Provider Information

NPI Number	:	1902816168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP JULIUS WELLS D.D.S.

Provider Business Mailing Address
First Line	:	3702 CLEVELAND AVE SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44707-1450
Country	:	US
Telephone Number	:	330-484-6401
Fax Number	:	330-484-3808

Provider Business Practice Location Address
First Line	:	3702 CLEVELAND AVE SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44707-1450
Country	:	US
Telephone Number	:	330-484-6401
Fax Number	:	330-484-3808

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

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/08/2007

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