Healthcare Provider Details

I. General information

NPI: 1992091730
Provider Name (Legal Business Name): JOHN WESLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 SE BISHOP BLVD
PULLMAN WA
99163-5452
US

IV. Provider business mailing address

1095 SE BISHOP BLVD
PULLMAN WA
99163-5452
US

V. Phone/Fax

Practice location:
  • Phone: 509-715-1700
  • Fax: 509-715-1030
Mailing address:
  • Phone: 509-715-1700
  • Fax: 509-715-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60233391
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60233391
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: