Provider Demographics
NPI:1659441103
Name:WOLF, MARK R (DDS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:WOLF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 W NORTH AVE.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2100
Mailing Address - Country:US
Mailing Address - Phone:630-941-3400
Mailing Address - Fax:360-941-3421
Practice Address - Street 1:533 W NORTH AVE.
Practice Address - Street 2:SUITE 200
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2100
Practice Address - Country:US
Practice Address - Phone:630-941-3400
Practice Address - Fax:360-941-3421
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0152971223S0112X
IL021.0009891223S0112X
IL019.0152971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-015297Medicaid
K51322Medicare UPIN
IL019-015297Medicaid
ILT37381Medicare UPIN