Provider Demographics
NPI:1144684002
Name:WOLF RIVER DENTAL LLC
Entity type:Organization
Organization Name:WOLF RIVER DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-709-8303
Mailing Address - Street 1:152 WOODLAWN DR
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2200
Mailing Address - Country:US
Mailing Address - Phone:715-526-3314
Mailing Address - Fax:
Practice Address - Street 1:152 WOODLAWN DR
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2200
Practice Address - Country:US
Practice Address - Phone:715-526-3314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STEPPING STONE DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental