Provider Demographics
NPI:1407011141
Name:JUPITER FAMILY DENTISTRY
Entity Type:Organization
Organization Name:JUPITER FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-746-2332
Mailing Address - Street 1:6779 W INDIANTOWN RD
Mailing Address - Street 2:#17
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458
Mailing Address - Country:US
Mailing Address - Phone:561-746-2332
Mailing Address - Fax:561-746-1815
Practice Address - Street 1:6779 W INDIANTOWN RD
Practice Address - Street 2:#17
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458
Practice Address - Country:US
Practice Address - Phone:561-746-2332
Practice Address - Fax:561-746-1815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10203122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
60589OtherBLUE CROSS BLUE SHEILD
443467OtherUNITED CONCORDIA