Healthcare Provider Details

I. General information

NPI: 1164535704
Provider Name (Legal Business Name): JOHN ROBERT OHNSTAD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 GRAND AVE
WAUSAU WI
54403
US

IV. Provider business mailing address

2110 GRAND AVE
WAUSAU WI
54403
US

V. Phone/Fax

Practice location:
  • Phone: 715-842-4111
  • Fax: 715-848-5269
Mailing address:
  • Phone: 715-842-4111
  • Fax: 715-848-5269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5001416015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: