Provider Demographics
NPI:1992091730
Name:WESLEY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WESLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 SE BISHOP BLVD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5452
Mailing Address - Country:US
Mailing Address - Phone:509-715-1700
Mailing Address - Fax:509-715-1030
Practice Address - Street 1:1095 SE BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5452
Practice Address - Country:US
Practice Address - Phone:509-715-1700
Practice Address - Fax:509-715-1030
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE602333911223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice