Provider Demographics
NPI:1740630326
Name:WELLE, KRISTINA B (DDS)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:B
Last Name:WELLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-1404
Mailing Address - Country:US
Mailing Address - Phone:906-524-6420
Mailing Address - Fax:
Practice Address - Street 1:12 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946
Practice Address - Country:US
Practice Address - Phone:906-524-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001442 - 15122300000X
MND14328122300000X
MI2901022135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist