Provider Demographics
NPI:1427219328
Name:WELLER, JODY A
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:A
Last Name:WELLER
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:PO BOX 27046
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-0134
Mailing Address - Country:US
Mailing Address - Phone:708-805-6565
Mailing Address - Fax:
Practice Address - Street 1:360 W SCHICK RD STE 17
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2965
Practice Address - Country:US
Practice Address - Phone:708-805-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020585122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist