Provider Demographics
NPI:1053429613
Name:WELLS, ROBERT HENRY JR (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:HENRY
Last Name:WELLS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice