Provider Demographics
NPI:1730238924
Name:WELLS, BRIAN (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:WELLS
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 1:3757 MARYWEATHER LN
Mailing Address - Street 2:101
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-7789
Mailing Address - Country:US
Mailing Address - Phone:813-907-7668
Mailing Address - Fax:
Practice Address - Street 1:3757 MARYWEATHER LN
Practice Address - Street 2:101
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-7789
Practice Address - Country:US
Practice Address - Phone:813-907-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN178401223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0206628Medicaid