Provider Demographics
NPI:1407940422
Name:OSTERHOUT, MARVIN JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:JAY
Last Name:OSTERHOUT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22221 7TH AVE S
Mailing Address - Street 2:STE B
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-6223
Mailing Address - Country:US
Mailing Address - Phone:206-878-2673
Mailing Address - Fax:206-870-7044
Practice Address - Street 1:22221 7TH AVE S
Practice Address - Street 2:STE B
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-6223
Practice Address - Country:US
Practice Address - Phone:206-878-2673
Practice Address - Fax:206-870-7044
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000058581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5083704Medicaid