Provider Demographics
NPI:1982667127
Name:WELLER, TODD SAMUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:SAMUEL
Last Name:WELLER
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 1:701 HOSPITAL LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-8704
Mailing Address - Country:US
Mailing Address - Phone:509-247-5829
Mailing Address - Fax:
Practice Address - Street 1:701 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-8704
Practice Address - Country:US
Practice Address - Phone:509-247-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE8663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist