Provider Demographics
NPI:1659670362
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:DOUG
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 1:1109 EAST MOORE LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432
Mailing Address - Country:US
Mailing Address - Phone:651-439-2600
Mailing Address - Fax:651-439-2211
Practice Address - Street 1:1109 EAST MOORE LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432
Practice Address - Country:US
Practice Address - Phone:651-439-2600
Practice Address - Fax:651-439-2211
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. CROIX VALLEY DENTAL, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND111236122300000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Single Specialty