Provider Demographics
NPI:1497966204
Name:WELLS, JOHN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
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 1:207 NORTH STREET
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906
Mailing Address - Country:US
Mailing Address - Phone:765-743-3122
Mailing Address - Fax:
Practice Address - Street 1:207 NORTH ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE BRA
Practice Address - State:IN
Practice Address - Zip Code:47906-3083
Practice Address - Country:US
Practice Address - Phone:765-743-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006340A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist