Provider Demographics
NPI:1396345963
Name:WELLS, JACK RANDALL JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:RANDALL
Last Name:WELLS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 STEAMBOAT PKWY UNIT 4801
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-6337
Mailing Address - Country:US
Mailing Address - Phone:505-363-8031
Mailing Address - Fax:
Practice Address - Street 1:9201 EAGLE RANCH RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-6440
Practice Address - Country:US
Practice Address - Phone:505-892-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00204532122300000X
NV7425T1223G0001X
NMDB-2023-0092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice