Provider Demographics
NPI:1124773460
Name:JUSTIN T. OSTREM D.D.S. PA
Entity type:Organization
Organization Name:JUSTIN T. OSTREM D.D.S. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:OSTREM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-536-1272
Mailing Address - Street 1:9655 SCHMIDT LAKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-4530
Mailing Address - Country:US
Mailing Address - Phone:763-536-1272
Mailing Address - Fax:
Practice Address - Street 1:9655 SCHMIDT LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-4530
Practice Address - Country:US
Practice Address - Phone:763-536-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty