Provider Demographics
NPI:1265448401
Name:WOLF, DUSTIN L (DC)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:L
Last Name:WOLF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1963 BETHEL RD SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3108
Mailing Address - Country:US
Mailing Address - Phone:360-876-3393
Mailing Address - Fax:360-895-0447
Practice Address - Street 1:1963 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3108
Practice Address - Country:US
Practice Address - Phone:360-876-3393
Practice Address - Fax:360-895-0447
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034426111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
8850493Medicare ID - Type Unspecified
WAV03058Medicare UPIN