Provider Demographics
NPI:1851796353
Name:OSTERTAG, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:OSTERTAG
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:S459 NORDEN RD
Mailing Address - Street 2:
Mailing Address - City:ELEVA
Mailing Address - State:WI
Mailing Address - Zip Code:54738-7805
Mailing Address - Country:US
Mailing Address - Phone:715-287-3453
Mailing Address - Fax:
Practice Address - Street 1:S459 NORDEN RD
Practice Address - Street 2:
Practice Address - City:ELEVA
Practice Address - State:WI
Practice Address - Zip Code:54738-7805
Practice Address - Country:US
Practice Address - Phone:715-287-3453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4211-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist