Provider Demographics
NPI:1760121586
Name:WOLF, JACOB AUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:AUSTIN
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 1:5075 161ST ST W APT 1127
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5525
Mailing Address - Country:US
Mailing Address - Phone:701-540-7945
Mailing Address - Fax:
Practice Address - Street 1:114 3RD ST N
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-2011
Practice Address - Country:US
Practice Address - Phone:507-263-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND24561223G0001X
MND147441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice