Provider Demographics
NPI:1659533859
Name:WELLS, MASON SULLIVAN (DMD)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:SULLIVAN
Last Name:WELLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10393 SOUTH 1300 WEST
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095
Mailing Address - Country:US
Mailing Address - Phone:801-254-1400
Mailing Address - Fax:801-254-7392
Practice Address - Street 1:10393 SOUTH 1300 WEST
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-254-1400
Practice Address - Fax:801-254-7392
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-28
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7014658-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist