Healthcare Provider Details

I. General information

NPI: 1629166350
Provider Name (Legal Business Name): LARRY F WOLFF D.D.S., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 VIKING DR STE 127
EDINA MN
55435-5306
US

IV. Provider business mailing address

4940 VIKING DR STE 127
EDINA MN
55435-5306
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-3383
  • Fax: 952-835-2818
Mailing address:
  • Phone: 952-835-3383
  • Fax: 952-835-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberMN8687
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: