Healthcare Provider Details

I. General information

NPI: 1184763468
Provider Name (Legal Business Name): RICHARD GRANT WELLS II D.D.S, M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 MAIN ST
CARBONDALE CO
81623-2138
US

IV. Provider business mailing address

1056 KINGS ROW ST
CARBONDALE CO
81623-9691
US

V. Phone/Fax

Practice location:
  • Phone: 970-963-3010
  • Fax: 970-963-4104
Mailing address:
  • Phone: 970-963-2747
  • Fax: 970-963-2747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8482
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: