Healthcare Provider Details

I. General information

NPI: 1295961514
Provider Name (Legal Business Name): TERRANCE MICHAEL WOLBAUM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5492 S PARKER RD
AURORA CO
80015-1136
US

IV. Provider business mailing address

2930 11TH AVE
EVANS CO
80620-1011
US

V. Phone/Fax

Practice location:
  • Phone: 303-766-8811
  • Fax:
Mailing address:
  • Phone: 970-353-9403
  • Fax: 970-353-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10189
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: