Provider Demographics
NPI:1154331221
Name:WOLFSEHR, BRIAN MITCHELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MITCHELL
Last Name:WOLFSEHR
Suffix:
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 1:1433 NE 69
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5301
Mailing Address - Country:US
Mailing Address - Phone:503-254-2402
Mailing Address - Fax:503-254-2402
Practice Address - Street 1:1433 NE 69TH
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5301
Practice Address - Country:US
Practice Address - Phone:503-254-2402
Practice Address - Fax:503-254-2402
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR53931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice