Provider Demographics
NPI:1992281075
Name:WELLS, MARK A (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:1950 S NARCOOSSEE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-7204
Mailing Address - Country:US
Mailing Address - Phone:217-540-5100
Mailing Address - Fax:
Practice Address - Street 1:1950 S NARCOOSSEE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34771-7204
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23660122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist