Provider Demographics
NPI:1760529978
Name:WOLFENDEN, TIMOTHY RAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RAND
Last Name:WOLFENDEN
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 1:14 DUVAL RD.
Mailing Address - Street 2:
Mailing Address - City:DUDLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01507-6820
Mailing Address - Country:US
Mailing Address - Phone:508-765-2821
Mailing Address - Fax:
Practice Address - Street 1:65 JAMES ST
Practice Address - Street 2:SUITE 204
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-1026
Practice Address - Country:US
Practice Address - Phone:508-753-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA167751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0269697Medicaid