Provider Demographics
NPI:1194221630
Name:WELLMAN, WESLEY ANN
Entity Type:Individual
Prefix:MISS
First Name:WESLEY
Middle Name:ANN
Last Name:WELLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-2407
Mailing Address - Country:US
Mailing Address - Phone:503-339-5134
Mailing Address - Fax:
Practice Address - Street 1:4575 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4645
Practice Address - Country:US
Practice Address - Phone:503-393-2651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5944124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist