1265618862 NPI number — ST. CROIX VALLEY DENTAL, PLLC

Table of content: (NPI 1265618862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265618862 NPI number — ST. CROIX VALLEY DENTAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. CROIX VALLEY DENTAL, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA/ CARMICHAEL DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265618862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13961 60TH ST NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-439-2600
Provider Business Mailing Address Fax Number:
651-439-2600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1003 PEARSON DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-377-9966
Provider Business Practice Location Address Fax Number:
715-377-9933
Provider Enumeration Date:
01/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WOLFF
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PWNER
Authorized Official Telephone Number:
651-439-2600

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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