Provider Demographics
NPI:1962744862
Name:WOLFENDEN, JAY RICHARD (DDS)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:RICHARD
Last Name:WOLFENDEN
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:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:WI
Mailing Address - Zip Code:54634
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:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50015241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice