MEDICARE: DR. TERRANCE MICHAEL WOLBAUM D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	10189	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295961514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRANCE MICHAEL WOLBAUM D.D.S.

Provider Business Mailing Address
First Line	:	2930 11TH AVE
Second Line	:
City	:	EVANS
State	:	CO
Zip	:	80620-1011
Country	:	US
Telephone Number	:	970-353-9403
Fax Number	:	970-353-9906

Provider Business Practice Location Address
First Line	:	5492 S PARKER RD
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80015-1136
Country	:	US
Telephone Number	:	303-766-8811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2009
Last Update Date	:	06/27/2016

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