Healthcare Provider Details

I. General information

NPI: 1114470580
Provider Name (Legal Business Name): JEREMY MANTLE WELLS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 CENTRAL AVE
EIELSON AFB AK
99702-2301
US

IV. Provider business mailing address

1615 TRUEMPER ST
JBSA LACKLAND TX
78236-5511
US

V. Phone/Fax

Practice location:
  • Phone: 907-377-6767
  • Fax:
Mailing address:
  • Phone: 210-292-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12590570-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: