Provider Demographics
NPI:1508448846
Name:WOLFENDEN FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:WOLFENDEN FAMILY DENTAL, PLLC
Other - Org Name:BERTHOUD DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-457-3418
Mailing Address - Street 1:329 BRONCO CT
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-2829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 BIMSON AVE
Practice Address - Street 2:
Practice Address - City:BERTHOUD
Practice Address - State:CO
Practice Address - Zip Code:80513-1395
Practice Address - Country:US
Practice Address - Phone:970-236-7448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental