Provider Demographics
NPI:1659566016
Name:DOLLOFF, WENDI (MT)
Entity Type:Individual
Prefix:
First Name:WENDI
Middle Name:
Last Name:DOLLOFF
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:WENDI
Other - Middle Name:
Other - Last Name:GRISWOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 BRAMBLEWOOD LANE
Mailing Address - Street 2:UNIT B
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038
Mailing Address - Country:US
Mailing Address - Phone:207-890-5272
Mailing Address - Fax:
Practice Address - Street 1:18 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1510
Practice Address - Country:US
Practice Address - Phone:207-890-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT2491174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME099638OtherANTHEM BLUE CROSS BLUE SH