Provider Demographics
NPI:1558466284
Name:WELLBAUM, RONALD L (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:WELLBAUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JOE
Other - Middle Name:
Other - Last Name:WELLBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:210 VALLEY MALL PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-7728
Mailing Address - Country:US
Mailing Address - Phone:509-886-2500
Mailing Address - Fax:509-886-3600
Practice Address - Street 1:210 VALLEY MALL PKWY
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-7728
Practice Address - Country:US
Practice Address - Phone:509-886-2500
Practice Address - Fax:509-886-3600
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA72051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5016910Medicaid
PA00904187OtherUNITED CONCORDIA COMPANY
WA8924565OtherLABOR & INDUSTRIES
WA8924565OtherLABOR & INDUSTRIES