Provider Demographics
NPI:1407138795
Name:WOLF, ELLEN PAULISICK (DDS, FAGD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:PAULISICK
Last Name:WOLF
Suffix:
Gender:F
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 FAISON RD STE 103
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9527
Mailing Address - Country:US
Mailing Address - Phone:843-654-1373
Mailing Address - Fax:
Practice Address - Street 1:405 FAISON ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466
Practice Address - Country:US
Practice Address - Phone:843-654-1373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15171122300000X
SC9462122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist