Provider Demographics
NPI:1962852772
Name:WOLF, JODY LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:WOLF
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4095 SW 144TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2368
Mailing Address - Country:US
Mailing Address - Phone:503-643-4719
Mailing Address - Fax:
Practice Address - Street 1:4095 SW 144TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2368
Practice Address - Country:US
Practice Address - Phone:503-643-4719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH 5251124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist