Provider Demographics
NPI:1053464800
Name:WOLF, LINDA
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:
Last Name:WOLF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HAWKINS STORE RD NW
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6204
Mailing Address - Country:US
Mailing Address - Phone:770-926-3400
Mailing Address - Fax:770-926-6317
Practice Address - Street 1:205 HAWKINS STORE RD NW
Practice Address - Street 2:SUITE A-1
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6204
Practice Address - Country:US
Practice Address - Phone:770-926-3400
Practice Address - Fax:770-926-6317
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0088211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00157924BMedicaid