Provider Demographics
NPI:1306417886
Name:WOLFE, KASSIDY (DMD)
Entity Type:Individual
Prefix:DR
First Name:KASSIDY
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 E SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-1332
Mailing Address - Country:US
Mailing Address - Phone:812-575-7204
Mailing Address - Fax:
Practice Address - Street 1:305 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:IN
Practice Address - Zip Code:47541-9656
Practice Address - Country:US
Practice Address - Phone:812-536-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013678A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice