MEDICARE: WOLF RIVER DENTAL LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1144684002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOLF RIVER DENTAL LLC

Provider Business Mailing Address
First Line	:	1040 ENGEL DR
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166
Country	:	US
Telephone Number	:	715-526-3314
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 ENGEL DR
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166
Country	:	US
Telephone Number	:	715-526-3314
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MGR
Name	:	AMANDA PONDZENSKI
Credential	:
Telephone Number	:	715-526-3314

Provider Enumeration Date	:	04/07/2016
Last Update Date	:	06/02/2026

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Directions to “WOLF RIVER DENTAL LLC ” Practice Location

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