Provider Demographics
NPI:1699839266
Name:JEFFREY A. WELLER, DDS, PC
Entity Type:Organization
Organization Name:JEFFREY A. WELLER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-654-0606
Mailing Address - Street 1:1050 N STATE ST
Mailing Address - Street 2:MEZZANINE LEVEL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-7829
Mailing Address - Country:US
Mailing Address - Phone:312-654-0606
Mailing Address - Fax:312-654-1606
Practice Address - Street 1:1050 N STATE ST
Practice Address - Street 2:MEZZANINE LEVEL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-7829
Practice Address - Country:US
Practice Address - Phone:312-654-0606
Practice Address - Fax:312-654-1606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190201471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty