Provider Demographics
NPI:1891011672
Name:WELLS, MICHAEL WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:WELLS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 WESTCLIFF DR
Mailing Address - Street 2:#204
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5524
Mailing Address - Country:US
Mailing Address - Phone:949-764-0122
Mailing Address - Fax:949-764-0131
Practice Address - Street 1:1617 WESTCLIFF DR
Practice Address - Street 2:#204
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5524
Practice Address - Country:US
Practice Address - Phone:949-764-0122
Practice Address - Fax:949-764-0131
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2010-04-19
Deactivation Date:2010-02-08
Deactivation Code:
Reactivation Date:2010-04-19
Provider Licenses
StateLicense IDTaxonomies
CA40510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist