Provider Demographics
NPI:1497819023
Name:WELLER, JEFFREY A (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:WELLER
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 1:1050 N STATE ST
Mailing Address - Street 2:MEZZANINE LEVEL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-7829
Mailing Address - Country:US
Mailing Address - Phone:312-654-0606
Mailing Address - Fax:312-654-1606
Practice Address - Street 1:1050 N STATE ST
Practice Address - Street 2:MEZZANINE LEVEL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-7829
Practice Address - Country:US
Practice Address - Phone:312-654-0606
Practice Address - Fax:312-654-1606
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190201471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice