Provider Demographics
NPI:1659355063
Name:WOLFORD, DONALD GARY (DDS)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:GARY
Last Name:WOLFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:D
Other - Middle Name:GARY
Other - Last Name:WOLFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:22811 MACK AVE
Mailing Address - Street 2:L1
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2021
Mailing Address - Country:US
Mailing Address - Phone:586-777-1331
Mailing Address - Fax:586-777-2358
Practice Address - Street 1:22811 MACK AVE
Practice Address - Street 2:L1
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-777-1331
Practice Address - Fax:586-777-2358
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010985204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9755060680OtherBLUE CROSS BLUE SHIELD
MI102991246Medicaid
MI9755060680OtherBLUE CROSS BLUE SHIELD
MI0M92420Medicare ID - Type Unspecified