Provider Demographics
NPI:1407166317
Name:NORTHERN ORTHODONTICS
Entity Type:Organization
Organization Name:NORTHERN ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-351-7777
Mailing Address - Street 1:13961 60TH ST N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-1053
Mailing Address - Country:US
Mailing Address - Phone:651-351-7777
Mailing Address - Fax:651-439-2211
Practice Address - Street 1:1109 MOORE LAKE DR E
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5171
Practice Address - Country:US
Practice Address - Phone:651-351-7777
Practice Address - Fax:651-439-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11236261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental