Provider Demographics
NPI:1598839748
Name:DAVID R WELLER DDS MS
Entity Type:Organization
Organization Name:DAVID R WELLER DDS MS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROBERTS
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:253-565-0330
Mailing Address - Street 1:4606 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466
Mailing Address - Country:US
Mailing Address - Phone:253-565-0330
Mailing Address - Fax:253-565-0296
Practice Address - Street 1:4606 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466
Practice Address - Country:US
Practice Address - Phone:253-565-0330
Practice Address - Fax:253-565-0296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000098981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty