Provider Demographics
NPI:1174761068
Name:WELLS, STACEY (RDH)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WELLS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7975 L STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127
Mailing Address - Country:US
Mailing Address - Phone:402-339-3187
Mailing Address - Fax:402-339-3914
Practice Address - Street 1:7975 L ST
Practice Address - Street 2:SUITE A
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-1731
Practice Address - Country:US
Practice Address - Phone:402-339-3187
Practice Address - Fax:402-339-3914
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1587124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025450000Medicaid