MEDICARE: ST CROIX VALLEY DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1295859676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST CROIX VALLEY DENTAL PLLC

Provider Business Mailing Address
First Line	:	11240 STILLWATER BLVD N
Second Line	:	LAKE ELMO DENTAL
City	:	LAKE ELMO
State	:	MN
Zip	:	55042
Country	:	US
Telephone Number	:	651-777-0210
Fax Number	:	651-777-0320

Provider Business Practice Location Address
First Line	:	10035 CITY WALK DR
Second Line	:	STE A LAKE ELMO DENTAL
City	:	LAKE ELMO
State	:	MN
Zip	:	55042
Country	:	US
Telephone Number	:	651-714-5555
Fax Number	:	651-439-2211

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. DOUGLAS STEVEN WOLFF
Credential	:	DDS
Telephone Number	:	651-439-2600

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	08/22/2020

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