Provider Demographics
NPI:1740259464
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: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 1:13961 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:651-439-2211
Practice Address - Street 1:13961 60TH ST. NORTH
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-2600
Practice Address - Fax:651-439-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7898122300000X
MND11236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty