Provider Demographics
NPI:1154002194
Name:WELLS, SAMUEL THOMAS (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:THOMAS
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 1:833 SW 11TH AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2118
Mailing Address - Country:US
Mailing Address - Phone:503-228-6870
Mailing Address - Fax:
Practice Address - Street 1:833 SW 11TH AVE STE 405
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2118
Practice Address - Country:US
Practice Address - Phone:503-228-6870
Practice Address - Fax:503-222-7189
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR118091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice