Provider Demographics
NPI:1063416055
Name:WELLS, MARVIN C (DMD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:C
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 1:4225 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL86833OtherBLUE CROSS BLUE SHIELD
FL86833OtherBLUE CROSS BLUE SHIELD