Provider Demographics
NPI:1801811732
Name:CHRISTOPHER R WELLS DMD PC
Entity type:Organization
Organization Name:CHRISTOPHER R WELLS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-345-2771
Mailing Address - Street 1:1880 JUDITH LN STE 210
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3185
Mailing Address - Country:US
Mailing Address - Phone:208-345-2771
Mailing Address - Fax:208-345-2888
Practice Address - Street 1:1880 JUDITH LN STE 210
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3185
Practice Address - Country:US
Practice Address - Phone:208-345-2771
Practice Address - Fax:208-345-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3568122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6J432OtherBLUE CROSS OF IDAHO
IDID03568AOtherDELTA DENTAL
ID806186200Medicaid
ID1347936OtherUNITED CONCORDIA