| Organization Name: | WOLF RIVER DENTAL LLC |
| NPI Number: | 1144684002 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TIMOTHY MATHISON (PRESIDENT & CEO) |
| Mailing Address: | 152 Woodlawn Dr Shawano |
| State: | WI US |
| Postal Code: | 541662200 |
| Phone Number: | 7155263314 |
| Fax Number: | |
| NPI Enumeration Date: | 04/07/2016 |
| NPI Last Update Date: | 04/07/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |