Provider Demographics
NPI:1124715883
Name:OSTERLING, COOPER
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:
Last Name:OSTERLING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5878 S PIKE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-9625
Mailing Address - Country:US
Mailing Address - Phone:218-390-4248
Mailing Address - Fax:
Practice Address - Street 1:17110 LAKESIDE HILLS PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-5600
Practice Address - Country:US
Practice Address - Phone:402-718-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE390200000X
NE7945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program