Provider Demographics
NPI:1164719126
Name:CASTRO, OLGA IVETT (DDS)
Entity Type:Individual
Prefix:DR
First Name:OLGA
Middle Name:IVETT
Last Name:CASTRO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 HIGHWAY 61 N STE 200
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2752
Mailing Address - Country:US
Mailing Address - Phone:651-429-3535
Mailing Address - Fax:
Practice Address - Street 1:4801 HIGHWAY 61 N STE 200
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2752
Practice Address - Country:US
Practice Address - Phone:651-429-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA559711223E0200X
MNS411223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics