Provider Demographics
NPI:1124514807
Name:WOLFF, MYRANDA NYCOLE (DMD)
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:NYCOLE
Last Name:WOLFF
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 PRAIRIE CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7156
Mailing Address - Country:US
Mailing Address - Phone:217-679-7727
Mailing Address - Fax:217-679-7471
Practice Address - Street 1:2740 PRAIRIE CROSSING DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7156
Practice Address - Country:US
Practice Address - Phone:217-679-7727
Practice Address - Fax:217-679-7471
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist