Provider Demographics
NPI:1245246818
Name:WOHLFORD, BRENT DOUGLAS (DMD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DOUGLAS
Last Name:WOHLFORD
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 1:5 SUNSET HILLS PROFESSIONAL CTR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3760
Mailing Address - Country:US
Mailing Address - Phone:618-692-4545
Mailing Address - Fax:618-655-0154
Practice Address - Street 1:5 SUNSET HILLS PROFESSIONAL CTR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3760
Practice Address - Country:US
Practice Address - Phone:618-692-4545
Practice Address - Fax:618-655-0154
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice