Provider Demographics
NPI:1386712537
Name:ROSTVOLD, JAMES DAVID (DDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVID
Last Name:ROSTVOLD
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 339
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-0330
Mailing Address - Country:US
Mailing Address - Phone:218-326-2560
Mailing Address - Fax:218-326-8256
Practice Address - Street 1:1043 E HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN09461122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN872720100Medicaid