MEDICARE: WELLS DENTISTRY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1449	WY

General Provider Information

NPI Number	:	1518491877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLS DENTISTRY PC

Provider Business Mailing Address
First Line	:	1933 EAST A STREET
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2224
Country	:	US
Telephone Number	:	307-237-8435
Fax Number	:	307-237-2841

Provider Business Practice Location Address
First Line	:	1933 EAST A STREET
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2224
Country	:	US
Telephone Number	:	307-237-8435
Fax Number	:	307-237-2841

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JESSICA NICOLE WELLS
Credential	:	D.D.S.
Telephone Number	:	307-237-8435

Provider Enumeration Date	:	04/13/2017
Last Update Date	:	04/13/2017

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