Provider Demographics
NPI:1477905990
Name:GANGESTAD, JUSTIN JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JAMES
Last Name:GANGESTAD
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 1:4940 CIRCLE PINES RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-9501
Mailing Address - Country:US
Mailing Address - Phone:218-851-8108
Mailing Address - Fax:
Practice Address - Street 1:13442 ELMWOOD DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8400
Practice Address - Country:US
Practice Address - Phone:218-829-4207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND137291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice