=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639723687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLBEING DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2019
-----------------------------------------------------
Last Update Date | 01/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1731 W BASELINE RD STE 104
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85202-5730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-757-7777
-----------------------------------------------------
Fax | 480-656-2888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1731 W BASELINE RD STE 104
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85202-5730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-757-7777
-----------------------------------------------------
Fax | 480-656-2888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | KRISTEN KARLSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-757-7777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------