Healthcare Provider Details

I. General information

NPI: 1336519990
Provider Name (Legal Business Name): MR. DEAN WELLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 PEGASUS DR NW
ALBUQUERQUE NM
87120-5714
US

IV. Provider business mailing address

5415 PEGASUS DR NW
ALBUQUERQUE NM
87120-5714
US

V. Phone/Fax

Practice location:
  • Phone: 505-659-6820
  • Fax: 505-841-4899
Mailing address:
  • Phone: 505-659-6820
  • Fax: 505-841-4899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-07763
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: