Healthcare Provider Details

I. General information

NPI: 1295800530
Provider Name (Legal Business Name): JONATHAN MARK WOHLFORD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 NELSON ST
RICHMOND VA
23228-5704
US

IV. Provider business mailing address

2105 NELSON ST
RICHMOND VA
23228-5704
US

V. Phone/Fax

Practice location:
  • Phone: 804-262-6587
  • Fax: 804-740-1207
Mailing address:
  • Phone: 804-262-6587
  • Fax: 804-740-1207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number0401006245
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: