Provider Demographics
NPI:1821402017
Name:KEVEN D WELLS DDS PC
Entity Type:Organization
Organization Name:KEVEN D WELLS DDS PC
Other - Org Name:LIVING WELL DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-793-0734
Mailing Address - Street 1:1516 LEGACY CIR
Mailing Address - Street 2:UNIT 104
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-1257
Mailing Address - Country:US
Mailing Address - Phone:630-505-1516
Mailing Address - Fax:
Practice Address - Street 1:1516 LEGACY CIR
Practice Address - Street 2:UNIT #104
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1257
Practice Address - Country:US
Practice Address - Phone:630-505-1516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty