Provider Demographics
NPI:1114229911
Name:D GARY WOLFORD DDS PC
Entity Type:Organization
Organization Name:D GARY WOLFORD DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOLFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-777-1331
Mailing Address - Street 1:22811 MACK AVE
Mailing Address - Street 2:SUITE L-1
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2021
Mailing Address - Country:US
Mailing Address - Phone:586-777-1331
Mailing Address - Fax:586-777-2358
Practice Address - Street 1:22811 MACK AVE
Practice Address - Street 2:SUITE L-1
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-777-1331
Practice Address - Fax:586-777-2358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010985204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9755060680OtherBLUE CROSS BLUE SHIELD
MI102991246Medicaid
MIU23186Medicare UPIN