Provider Demographics
NPI:1427480177
Name:OSTERHAUS, JACK EDGAR (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:EDGAR
Last Name:OSTERHAUS
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 1:2424 CHARTRES STREET
Mailing Address - Street 2:
Mailing Address - City:LASALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-1107
Mailing Address - Country:US
Mailing Address - Phone:815-223-6013
Mailing Address - Fax:
Practice Address - Street 1:2424 CHARTRES STREET
Practice Address - Street 2:
Practice Address - City:LASALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-1107
Practice Address - Country:US
Practice Address - Phone:815-223-6013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0295671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice