Provider Demographics
NPI:1306968458
Name:J R WOLFENDEN DDS SC
Entity type:Organization
Organization Name:J R WOLFENDEN DDS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOLFENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-489-3499
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:WI
Mailing Address - Zip Code:54634-0031
Mailing Address - Country:US
Mailing Address - Phone:608-489-3499
Mailing Address - Fax:
Practice Address - Street 1:925 WATER AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634
Practice Address - Country:US
Practice Address - Phone:608-489-3499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001524015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33660600Medicaid