MEDICARE: DR. KEITH WOLFENDEN DMD

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	122300000X	Dentist	DEN.00203846	CO

General Provider Information

NPI Number	:	1629382981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH WOLFENDEN DMD

Provider Business Mailing Address
First Line	:	329 BRONCO CT
Second Line	:
City	:	BERTHOUD
State	:	CO
Zip	:	80513-2829
Country	:	US
Telephone Number	:	904-703-2782
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 BIMSON AVE
Second Line	:
City	:	BERTHOUD
State	:	CO
Zip	:	80513-1395
Country	:	US
Telephone Number	:	970-532-4209
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2010
Last Update Date	:	11/22/2022

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