Provider Demographics
NPI:1134114465
Name:OSTERBERG, STIG K A (DDS MSD)
Entity Type:Individual
Prefix:DR
First Name:STIG
Middle Name:K A
Last Name:OSTERBERG
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:PT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6525
Mailing Address - Country:US
Mailing Address - Phone:360-385-5121
Mailing Address - Fax:360-379-9534
Practice Address - Street 1:1119 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:PT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6525
Practice Address - Country:US
Practice Address - Phone:360-385-5121
Practice Address - Fax:360-379-9534
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00005095122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
662902093OtherACA
0156577OtherL AND I
662902093OtherACA