Provider Demographics
NPI:1932397924
Name:WOLFF, SHAWN NICHOLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:NICHOLAS
Last Name:WOLFF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:SHAWN
Other - Middle Name:NICHOLAS
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1424A FERN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-9376
Mailing Address - Country:US
Mailing Address - Phone:704-749-4141
Mailing Address - Fax:704-871-1545
Practice Address - Street 1:1424A FERN CREEK DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9376
Practice Address - Country:US
Practice Address - Phone:704-749-4141
Practice Address - Fax:704-871-1505
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC84561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908307Medicaid