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General NPI Number Information
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NPI Number | 1023467289
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Entity Type | Individual
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Provider Name | CLAUS JOHAN ULLSTAD DDS, MS, MMS
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Gender | Male
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Dates
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Enumeration Date | 06/08/2016
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Last Update Date | 09/10/2024
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Provider Practice Location Address
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Address Line | BUDGE DENTAL CLINIC 3145 GARDEN AVE #1278
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City | FORT SAM HOUSTON
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State | TX
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Zip | 78234
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Country | US
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Telephone | 210-808-2434
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Fax |
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Provider Business Mailing Address
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Address Line | NMRTCC SAN ANTONIO/SAMMC LNO 3851 ROGER BROOKE DRIVE
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City | SAN ANTONIO
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State | TX
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Zip | 78234
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Country | US
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Telephone | 210-808-2434
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 0401416394
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License Number State | VA
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