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General NPI Number Information
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NPI Number | 1679800239
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Entity Type | Organization
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Legal Business Name | OSTERTAG ORTHODONTICS, LLC
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Dates
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Enumeration Date | 11/03/2009
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Last Update Date | 11/03/2009
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Provider Practice Location Address
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Address Line | 4907 KEYSTONE XING SUITE A
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City | EAU CLAIRE
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State | WI
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Zip | 54701-5144
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Country | US
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Telephone | 715-855-5051
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Fax | 715-855-5052
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Provider Business Mailing Address
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Address Line | 4907 KEYSTONE XING SUITE A
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City | EAU CLAIRE
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State | WI
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Zip | 54701-5144
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Country | US
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Telephone | 715-855-5051
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Fax | 715-855-5052
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Authorized Official
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Title or Position | OWNER
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Name | ALAN OSTERTAG
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Credential | DDS, MS
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Telephone | 715-255-5051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 3726-015
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License Number State | WI
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