Healthcare Provider Details

I. General information

NPI: 1467997106
Provider Name (Legal Business Name): WOLFY DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 S WHITTLESEY AVE
WALLINGFORD CT
06492-4101
US

IV. Provider business mailing address

51 S WHITTLESEY AVE
WALLINGFORD CT
06492-4101
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-3139
  • Fax: 203-265-5133
Mailing address:
  • Phone: 203-265-3139
  • Fax: 203-265-5133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11226
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number006306
License Number StateCT

VIII. Authorized Official

Name: DR. SANDRA VUKOVIC
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 203-265-3139