Provider Demographics
NPI:1891885000
Name:ST CROIX VALLEY DENTAL PLLC
Entity Type:Organization
Organization Name:ST CROIX VALLEY DENTAL PLLC
Other - Org Name:LAKE ELMO DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-777-0210
Mailing Address - Street 1:11240 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042
Mailing Address - Country:US
Mailing Address - Phone:651-777-0210
Mailing Address - Fax:651-777-0320
Practice Address - Street 1:11240 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55128
Practice Address - Country:US
Practice Address - Phone:651-777-0210
Practice Address - Fax:651-777-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty