Provider Demographics
NPI:1700429826
Name:WELLS, MIKIALA CHAE (RDH, BSDH)
Entity Type:Individual
Prefix:MRS
First Name:MIKIALA
Middle Name:CHAE
Last Name:WELLS
Suffix:
Gender:F
Credentials:RDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 CATAWBA ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4502
Mailing Address - Country:US
Mailing Address - Phone:276-870-1378
Mailing Address - Fax:
Practice Address - Street 1:1647 E STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4609
Practice Address - Country:US
Practice Address - Phone:423-245-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7324124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist