Provider Demographics
NPI:1891189759
Name:WELLES, ANDREW D (DDS)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:D
Last Name:WELLES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 W BELTLINE HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-4226
Mailing Address - Country:US
Mailing Address - Phone:608-443-5500
Mailing Address - Fax:608-441-2385
Practice Address - Street 1:2202 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1916
Practice Address - Country:US
Practice Address - Phone:608-443-5482
Practice Address - Fax:608-443-5534
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001099-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1891189759Medicaid