Provider Demographics
NPI:1730597709
Name:WOLF, BRANDON (DMD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 LEGION DR
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2415
Mailing Address - Country:US
Mailing Address - Phone:330-502-7292
Mailing Address - Fax:
Practice Address - Street 1:16506 POINTE VILLAGE DR.
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647
Practice Address - Country:US
Practice Address - Phone:813-906-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007302-C122300000X
PADS039738122300000X
SC8352122300000X
FLDN28661.122300000X
FLDN28661122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist