Healthcare Provider Details

I. General information

NPI: 1457529885
Provider Name (Legal Business Name): BRIAN MICHAEL WELLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

IV. Provider business mailing address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-6275
  • Fax: 612-904-4234
Mailing address:
  • Phone: 612-873-6005
  • Fax: 612-630-8242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberR391
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: