Provider Demographics
NPI:1619144540
Name:ST. CROIX VALLEY DENTAL, PLLC
Entity Type:Organization
Organization Name:ST. CROIX VALLEY DENTAL, PLLC
Other - Org Name:ROSEMOUNT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-439-2600
Mailing Address - Street 1:14895 S ROBERT TRL
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-3108
Mailing Address - Country:US
Mailing Address - Phone:952-423-2288
Mailing Address - Fax:952-423-2203
Practice Address - Street 1:14895 S ROBERT TRL
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-3108
Practice Address - Country:US
Practice Address - Phone:952-423-2288
Practice Address - Fax:952-423-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11236305S00000X
MND11480305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN275435000OtherMHCP
WI071695000OtherMHCP
MN617665000OtherMINNESOTA HEALTH CARE PROVIDER
MN897945000OtherMHCP
WI38396800OtherMHCP