Provider Demographics
NPI:1831277136
Name:WOLF, TYLER ANDREW (DDS)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:ANDREW
Last Name:WOLF
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 1:7678 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428
Mailing Address - Country:US
Mailing Address - Phone:616-457-4600
Mailing Address - Fax:616-457-6021
Practice Address - Street 1:7678 COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428
Practice Address - Country:US
Practice Address - Phone:616-457-4600
Practice Address - Fax:616-457-6021
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017916122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1367809OtherUNITED CONCORDIA