Provider Demographics
NPI:1346655974
Name:WOLF, JAKE BRADY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:BRADY
Last Name:WOLF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 GOLF COURSE RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5842
Mailing Address - Country:US
Mailing Address - Phone:505-892-9010
Mailing Address - Fax:
Practice Address - Street 1:1310 E PINE ST
Practice Address - Street 2:SUITE B
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-7003
Practice Address - Country:US
Practice Address - Phone:575-544-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist