Healthcare Provider Details

I. General information

NPI: 1013216811
Provider Name (Legal Business Name): MINNEAPOLIS-ST. PAUL PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 EAST MOORE LAKE DRIVE
FRIDLEY MN
55432
US

IV. Provider business mailing address

1109 EAST MOORE LAKE DRIVE
FRIDLEY MN
55432
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-2600
  • Fax: 651-439-2211
Mailing address:
  • Phone: 651-439-2600
  • Fax: 651-439-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD11710
License Number StateMN

VIII. Authorized Official

Name: DR. DOUG S WOLFF
Title or Position: OWNER
Credential: D.D.S.
Phone: 651-439-2600