Healthcare Provider Details

I. General information

NPI: 1346724234
Provider Name (Legal Business Name): GREGORY WELLS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 LOMAS BLVD NE
ALBUQUERQUE NM
87110-6539
US

IV. Provider business mailing address

1513 TEJANA MESA PL NE
ALBUQUERQUE NM
87112-6574
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-6388
  • Fax:
Mailing address:
  • Phone: 505-350-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4979
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: