Provider Demographics
NPI:1679912844
Name:OOSTHUIZEN, PIETER FREDERICK (LD)
Entity Type:Individual
Prefix:
First Name:PIETER
Middle Name:FREDERICK
Last Name:OOSTHUIZEN
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 N 5TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9874
Mailing Address - Country:US
Mailing Address - Phone:541-899-9999
Mailing Address - Fax:
Practice Address - Street 1:725 N 5TH ST
Practice Address - Street 2:STE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9873
Practice Address - Country:US
Practice Address - Phone:541-899-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10152790122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist