Healthcare Provider Details

I. General information

NPI: 1356854442
Provider Name (Legal Business Name): SMILE ORTHODONTICS STILLWATER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 HENNEPIN AVE
MINNEAPOLIS MN
55405-2737
US

IV. Provider business mailing address

1041 GRAND AVE # 531
SAINT PAUL MN
55105-3002
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD11236
License Number StateMN

VIII. Authorized Official

Name: DR. DOUGLAS STEVEN WOLFF
Title or Position: DENTIST
Credential: DDS
Phone: 651-351-7777