MEDICARE: DOUGLAS A. WOLFE DDS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1104514777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS A. WOLFE DDS PLLC

Provider Business Mailing Address
First Line	:	1532 PROVIDENCE RD S STE 220
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-8313
Country	:	US
Telephone Number	:	704-373-6040
Fax Number	:	704-373-6041

Provider Business Practice Location Address
First Line	:	1532 PROVIDENCE RD S STE 220
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-8313
Country	:	US
Telephone Number	:	704-373-6040
Fax Number	:	704-373-6041

Authorized Official
Title or Position	:	OWNER AND PRESIDENT
Name	:	DR. DOUGLAS ANDREW WOLFE
Credential	:	D.D.S.
Telephone Number	:	330-348-6024

Provider Enumeration Date	:	05/01/2023
Last Update Date	:	04/09/2024

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