Provider Demographics
NPI:1508980442
Name:JOE, WELLINGTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:WELLINGTON
Middle Name:
Last Name:JOE
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 1:23545 CRENSHAW BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5282
Mailing Address - Country:US
Mailing Address - Phone:310-530-9893
Mailing Address - Fax:310-530-5756
Practice Address - Street 1:23545 CRENSHAW BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5282
Practice Address - Country:US
Practice Address - Phone:310-530-9893
Practice Address - Fax:310-530-5756
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA255491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice