Provider Demographics
NPI:1396833554
Name:WHOOLERY DENTISTRY, P.C.
Entity Type:Organization
Organization Name:WHOOLERY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WHOOLERY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-739-2217
Mailing Address - Street 1:219 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2236
Mailing Address - Country:US
Mailing Address - Phone:218-739-2217
Mailing Address - Fax:218-739-2443
Practice Address - Street 1:219 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2236
Practice Address - Country:US
Practice Address - Phone:218-739-2217
Practice Address - Fax:218-739-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND95051223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN954220500Medicaid