Provider Demographics
NPI:1609045681
Name:WOLFRUM, CARLA ROXANN (LD)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:ROXANN
Last Name:WOLFRUM
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E SUPERIOR ST
Mailing Address - Street 2:SUITE #9
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1275
Mailing Address - Country:US
Mailing Address - Phone:208-255-5577
Mailing Address - Fax:208-255-5577
Practice Address - Street 1:204 E SUPERIOR ST
Practice Address - Street 2:SUITE #9
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1275
Practice Address - Country:US
Practice Address - Phone:208-255-5577
Practice Address - Fax:208-255-5577
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD9122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist