Provider Demographics
NPI:1649255944
Name:WOOLWINE, FRED ASHLEY JR (DDS)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:ASHLEY
Last Name:WOOLWINE
Suffix:JR
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 1:2103 CANDIES LN NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2618
Mailing Address - Country:US
Mailing Address - Phone:423-310-8585
Mailing Address - Fax:
Practice Address - Street 1:201 DOOLEY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-6220
Practice Address - Country:US
Practice Address - Phone:423-728-7020
Practice Address - Fax:423-479-6130
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0002748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist