Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DN008821 | GA |
NPI | 1053464800 |
---|---|
Provider Name | Dr. Linda Wolf |
First Address | Kennesaw, GA 30144-6204 |
Second Address | Kennesaw, GA 30144-6204 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00157924B | (05) | GA |