Provider Demographics
NPI:1033219290
Name:DEWOLF, JOHN BYRON III (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BYRON
Last Name:DEWOLF
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1631
Mailing Address - Country:US
Mailing Address - Phone:715-823-2233
Mailing Address - Fax:715-823-5720
Practice Address - Street 1:112 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1631
Practice Address - Country:US
Practice Address - Phone:715-823-2233
Practice Address - Fax:715-823-5720
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29191223G0001X
PA223171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33439900Medicaid
WI1033219290Medicare UPIN