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General NPI Number Information
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NPI Number | 1609045681
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Entity Type | Individual
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Provider Name | CARLA ROXANN WOLFRUM LD
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Gender | Female
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Dates
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Enumeration Date | 02/25/2008
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Last Update Date | 02/25/2008
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Provider Practice Location Address
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Address Line | 204 E SUPERIOR ST SUITE #9
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City | SANDPOINT
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State | ID
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Zip | 83864-1275
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Country | US
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Telephone | 208-255-5577
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Fax | 208-255-5577
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Provider Business Mailing Address
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Address Line | 204 E SUPERIOR ST SUITE #9
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City | SANDPOINT
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State | ID
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Zip | 83864-1275
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Country | US
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Telephone | 208-255-5577
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Fax | 208-255-5577
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | LD9
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License Number State | ID
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