Healthcare Provider Details

I. General information

NPI: 1982667127
Provider Name (Legal Business Name): TODD SAMUEL WELLER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HOSPITAL LOOP
FAIRCHILD AFB WA
99011-8704
US

IV. Provider business mailing address

701 HOSPITAL LOOP
FAIRCHILD AFB WA
99011-8704
US

V. Phone/Fax

Practice location:
  • Phone: 509-247-5829
  • Fax:
Mailing address:
  • Phone: 509-247-5829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE8663
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: