Provider Demographics
NPI:1740202118
Name:WOLFERT, JEROME HAROLD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:HAROLD
Last Name:WOLFERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MINEOLA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3918
Mailing Address - Country:US
Mailing Address - Phone:516-248-6018
Mailing Address - Fax:516-248-6246
Practice Address - Street 1:140 MINEOLA BLVD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3918
Practice Address - Country:US
Practice Address - Phone:516-248-6018
Practice Address - Fax:516-248-6246
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029379-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice