Healthcare Provider Details

I. General information

NPI: 1649340050
Provider Name (Legal Business Name): SEAN PATRICK VOSTAD BS, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 2ND AVE S BOX 515
SAINT JAMES MN
56081-1737
US

IV. Provider business mailing address

104 PLAINVIEW STREET BOX 97
EAGLE LAKE MN
56024
US

V. Phone/Fax

Practice location:
  • Phone: 507-375-4611
  • Fax: 507-257-3456
Mailing address:
  • Phone: 507-257-3800
  • Fax: 507-257-3456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11770
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: