Provider Demographics
NPI:1770691990
Name:BWDENTISTRY
Entity type:Organization
Organization Name:BWDENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-775-3201
Mailing Address - Street 1:200 E CHOCTAW AVE
Mailing Address - Street 2:PO BOX 625
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4604
Mailing Address - Country:US
Mailing Address - Phone:918-775-3201
Mailing Address - Fax:918-775-3394
Practice Address - Street 1:200 E CHOCTAW AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4604
Practice Address - Country:US
Practice Address - Phone:918-775-3201
Practice Address - Fax:918-775-3394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty