Healthcare Provider Details

I. General information

NPI: 1396345963
Provider Name (Legal Business Name): JACK RANDALL WELLS JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2020
Last Update Date: 10/01/2023
Certification Date: 10/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 EAGLE RANCH RD NW
ALBUQUERQUE NM
87114-6440
US

IV. Provider business mailing address

1851 STEAMBOAT PKWY UNIT 4801
RENO NV
89521-6337
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-9010
  • Fax:
Mailing address:
  • Phone: 505-363-8031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00204532
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7425T
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2023-0092
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: