Provider Demographics
NPI:1609589837
Name:CLARK, JULIE KOLSTAD
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:KOLSTAD
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 SE BLAKELEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-4828
Mailing Address - Country:US
Mailing Address - Phone:541-817-2181
Mailing Address - Fax:
Practice Address - Street 1:150 NE KENNETH FORD DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1042
Practice Address - Country:US
Practice Address - Phone:541-672-9596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-TMP-10228509122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist