=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447705165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELL BEING ENDO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2016
-----------------------------------------------------
Last Update Date | 08/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 266 NW PEACOCK BLVD SUITE 103
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-2271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-340-2242
-----------------------------------------------------
Fax | 772-340-7290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 266 NW PEACOCK BLVD SUITE 103
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-2271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-340-2242
-----------------------------------------------------
Fax | 772-340-7290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUAN SAVELLI
-----------------------------------------------------
Credential | DMD MSD
-----------------------------------------------------
Telephone | 561-543-1995
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | DN16441
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------