Provider Demographics
NPI:1285795930
Name:ROMSTAD, JOHN M (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:ROMSTAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:CLARISSA
Mailing Address - State:MN
Mailing Address - Zip Code:56440-0416
Mailing Address - Country:US
Mailing Address - Phone:218-756-2234
Mailing Address - Fax:218-756-2427
Practice Address - Street 1:214 MAIN STREET WEST
Practice Address - Street 2:
Practice Address - City:CLARISSA
Practice Address - State:MN
Practice Address - Zip Code:56440
Practice Address - Country:US
Practice Address - Phone:218-756-2234
Practice Address - Fax:218-756-2427
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN613318500Medicaid
MN613318500Medicaid