Provider Demographics
NPI:1467997106
Name:WOLFY DENTAL GROUP LLC
Entity Type:Organization
Organization Name:WOLFY DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:VUKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-265-3139
Mailing Address - Street 1:51 S WHITTLESEY AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4101
Mailing Address - Country:US
Mailing Address - Phone:203-265-3139
Mailing Address - Fax:203-265-5133
Practice Address - Street 1:51 S WHITTLESEY AVE
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4101
Practice Address - Country:US
Practice Address - Phone:203-265-3139
Practice Address - Fax:203-265-5133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT112261223G0001X
CT0063061223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1346658051Medicaid
CT1962429399Medicaid