Provider Demographics
NPI:1801140678
Name:WELLS ORAL & MAXILLOFACIAL SURGERY ASSOCIATION
Entity type:Organization
Organization Name:WELLS ORAL & MAXILLOFACIAL SURGERY ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-296-2226
Mailing Address - Street 1:4225 SOUTHPOINT PKWY S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0975
Mailing Address - Country:US
Mailing Address - Phone:904-296-2226
Mailing Address - Fax:904-296-8887
Practice Address - Street 1:4225 SOUTHPOINT PKWY S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0975
Practice Address - Country:US
Practice Address - Phone:904-296-2226
Practice Address - Fax:904-296-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0747998-00Medicaid
FL86833OtherBLUE CROSS & BLUE SHIELD
FLT55297Medicare UPIN