MEDICARE: DR. JAMES KOLSTAD DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	1001113-15	WI
2	1223G0001X	General Practice Dentistry	1001113-15	WI

General Provider Information

NPI Number	:	1336511716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES KOLSTAD DDS

Provider Business Mailing Address
First Line	:	2140 W SAINT PAUL AVE STE A
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-5905
Country	:	US
Telephone Number	:	262-547-2827
Fax Number	:

Provider Business Practice Location Address
First Line	:	2140 W SAINT PAUL AVE STE A
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-5905
Country	:	US
Telephone Number	:	262-547-2827
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2015
Last Update Date	:	10/06/2020

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