Healthcare Provider Details

I. General information

NPI: 1407166317
Provider Name (Legal Business Name): NORTHERN ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 MOORE LAKE DR E
FRIDLEY MN
55432-5171
US

IV. Provider business mailing address

13961 60TH ST N
STILLWATER MN
55082-1053
US

V. Phone/Fax

Practice location:
  • Phone: 651-351-7777
  • Fax: 651-439-2211
Mailing address:
  • Phone: 651-351-7777
  • Fax: 651-439-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number11236
License Number StateMN

VIII. Authorized Official

Name: DR. DOUGLAS S WOLFF
Title or Position: OWNER
Credential:
Phone: 651-351-7777