Provider Demographics
NPI:1437178316
Name:WELLS, RANDLE LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDLE
Middle Name:LEE
Last Name:WELLS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6427
Mailing Address - Country:US
Mailing Address - Phone:706-869-1818
Mailing Address - Fax:
Practice Address - Street 1:1332 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6427
Practice Address - Country:US
Practice Address - Phone:706-869-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4892122300000X
GADN 014063122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278159Medicaid
AL529925330Medicaid