Provider Demographics
NPI:1710182183
Name:SPIRIT DENTAL, LLC
Entity Type:Organization
Organization Name:SPIRIT DENTAL, LLC
Other - Org Name:JACK E. WOLF D.M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-530-7260
Mailing Address - Street 1:109 LONG RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005
Mailing Address - Country:US
Mailing Address - Phone:636-530-7260
Mailing Address - Fax:636-733-9084
Practice Address - Street 1:109 LONG RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005
Practice Address - Country:US
Practice Address - Phone:636-530-7260
Practice Address - Fax:636-733-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0146161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty