Provider Demographics
NPI:1750399713
Name:WOLFF, JOHN L III (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:WOLFF
Suffix:III
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 1:1683 WILLISTON ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6426
Mailing Address - Country:US
Mailing Address - Phone:802-864-9111
Mailing Address - Fax:802-658-3970
Practice Address - Street 1:1683 WILLISTON ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6426
Practice Address - Country:US
Practice Address - Phone:802-864-9111
Practice Address - Fax:802-658-3970
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600006951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
065862OtherUNITED CONCORDIA
VT0001915Medicaid