Provider Demographics
NPI:1760593008
Name:ROLAND P WOLFERSTETTER DDS LLC
Entity Type:Organization
Organization Name:ROLAND P WOLFERSTETTER DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:WOLFERSTETTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-464-8600
Mailing Address - Street 1:9235 W CAPITOL DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1567
Mailing Address - Country:US
Mailing Address - Phone:414-464-8600
Mailing Address - Fax:414-464-8603
Practice Address - Street 1:9235 W CAPITOL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1567
Practice Address - Country:US
Practice Address - Phone:414-464-8600
Practice Address - Fax:414-464-8603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI333 72 700Medicaid