Basic Information
| Provider Information | |||||||||
| NPI: | 1396345963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | RANDALL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1851 STEAMBOAT PKWY UNIT 4801 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895216337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053638031 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2436 S ACADEMY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809162408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193912336 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2020 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.00204532 | CO | Y | Dental Providers | Dentist | 1223G0001X | 7425T | NV | N | Dental Providers | Dentist | General Practice |
No ID Information.