Healthcare Provider Details

I. General information

NPI: 1740630326
Provider Name (Legal Business Name): KRISTINA B WELLE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 S 4TH ST
LANSE MI
49946
US

IV. Provider business mailing address

12 S 4TH ST
LANSE MI
49946-1404
US

V. Phone/Fax

Practice location:
  • Phone: 906-524-6420
  • Fax:
Mailing address:
  • Phone: 906-524-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1001442 - 15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14328
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022135
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: