Healthcare Provider Details

I. General information

NPI: 1497966204
Provider Name (Legal Business Name): JOHN L WELLS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 NORTH ST
WEST LAFAYETTE BRA IN
47906-3083
US

IV. Provider business mailing address

207 NORTH STREET
WEST LAFAYETTE IN
47906
US

V. Phone/Fax

Practice location:
  • Phone: 765-743-3122
  • Fax:
Mailing address:
  • Phone: 765-743-3122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12006340A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: