Provider Demographics
NPI:1467511956
Name:WOLKEN, STACEY KAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:KAY
Last Name:WOLKEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7216 GUNFLINT TRL
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-7576
Mailing Address - Country:US
Mailing Address - Phone:612-708-3547
Mailing Address - Fax:
Practice Address - Street 1:18315 CASCADE DR
Practice Address - Street 2:SUITE 120
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-1180
Practice Address - Country:US
Practice Address - Phone:952-949-2536
Practice Address - Fax:952-949-3942
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN298483100Medicaid