Provider Demographics
NPI:1174659791
Name:WELLS, BRETT R (DMD)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:R
Last Name:WELLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 NO GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1724
Mailing Address - Country:US
Mailing Address - Phone:435-882-1381
Mailing Address - Fax:435-833-0812
Practice Address - Street 1:668 NO GARDEN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1724
Practice Address - Country:US
Practice Address - Phone:435-882-1381
Practice Address - Fax:435-833-0812
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3243571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
682352OtherUNITED CONCORDIA
UT35435799200001OtherBLUE CROSS BLUE SHIELD