Provider Demographics
NPI:1053865147
Name:WOLF, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8150 T N SKILES RD
Mailing Address - Street 2:
Mailing Address - City:PONDER
Mailing Address - State:TX
Mailing Address - Zip Code:76259-5854
Mailing Address - Country:US
Mailing Address - Phone:940-479-2884
Mailing Address - Fax:
Practice Address - Street 1:8150 T N SKILES RD
Practice Address - Street 2:
Practice Address - City:PONDER
Practice Address - State:TX
Practice Address - Zip Code:76259-5854
Practice Address - Country:US
Practice Address - Phone:940-479-2884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice