Healthcare Provider Details

I. General information

NPI: 1427153642
Provider Name (Legal Business Name): ADAM BRENT WELLS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2634 ESCALA CIR
SAN DIEGO CA
92108-6720
US

IV. Provider business mailing address

2634 ESCALA CIR
SAN DIEGO CA
92108-6720
US

V. Phone/Fax

Practice location:
  • Phone: 502-548-7118
  • Fax: 502-852-7163
Mailing address:
  • Phone: 502-548-7118
  • Fax: 502-852-7163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8418
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number57123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: