Provider Demographics
NPI:1194327478
Name:WELLS, JUDSON WILLIAM JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:WILLIAM
Last Name:WELLS
Suffix:JR
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:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-0048
Mailing Address - Country:US
Mailing Address - Phone:251-459-4684
Mailing Address - Fax:
Practice Address - Street 1:130 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3121
Practice Address - Country:US
Practice Address - Phone:516-231-1742
Practice Address - Fax:516-284-1233
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.6812-C11223G0001X
NY0614531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice