Provider Demographics
NPI:1265618862
Name:ST. CROIX VALLEY DENTAL, PLLC
Entity type:Organization
Organization Name:ST. CROIX VALLEY DENTAL, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PWNER
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 1:13961 60TH ST NORTH
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-439-2600
Mailing Address - Fax:651-439-2600
Practice Address - Street 1:1003 PEARSON DR.
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016
Practice Address - Country:US
Practice Address - Phone:715-377-9966
Practice Address - Fax:715-377-9933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. CROIX VALLEY DENTAL, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service