Basic Information
| Provider Information | |||||||||
| NPI: | 1184875882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | SYRETTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4930 GOVERNORS DR | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | FOREST PARK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302976101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043631700 | ||||||||
| FaxNumber: | 4043630700 | ||||||||
| Practice Location | |||||||||
| Address1: | 4930 GOVERNORS DR | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | FOREST PARK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302976101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043631700 | ||||||||
| FaxNumber: | 4043630700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2008 | ||||||||
| LastUpdateDate: | 10/01/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN13505 | GA | N | Dental Providers | Dentist | General Practice | 1223P0700X | DN13505 | GA | Y | Dental Providers | Dentist | Prosthodontics |
No ID Information.