Provider Demographics
NPI:1437222148
Name:WOLF, PHILLIP JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JAMES
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 1:331 CLOVER BROOK DR
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1086
Mailing Address - Country:US
Mailing Address - Phone:989-725-1210
Mailing Address - Fax:
Practice Address - Street 1:222 N PARK ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-3042
Practice Address - Country:US
Practice Address - Phone:989-725-7825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist