=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982717708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK A WOLFSON DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 01/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26601 COOLIDGE HWY
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-352-2266
-----------------------------------------------------
Fax | 248-352-2267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26601 COOLIDGE HWY
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48237-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-352-2266
-----------------------------------------------------
Fax | 248-352-2267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK ALLAN WOLFSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 248-352-2266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 15637
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------