Provider Demographics
NPI:1821690496
Name:SMILE ORTHODONTICS STILLWATER LLC
Entity Type:Organization
Organization Name:SMILE ORTHODONTICS STILLWATER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-351-7777
Mailing Address - Street 1:1041 GRAND AVE # 531
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3002
Mailing Address - Country:US
Mailing Address - Phone:651-351-7777
Mailing Address - Fax:
Practice Address - Street 1:9424 DUNKIRK LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-1220
Practice Address - Country:US
Practice Address - Phone:651-351-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMILE ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty