Provider Demographics
NPI:1942238621
Name:NUSTAD, ROBERT A (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:NUSTAD
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 HILLCREST AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3680
Mailing Address - Country:US
Mailing Address - Phone:507-451-0290
Mailing Address - Fax:507-451-0291
Practice Address - Street 1:605 HILLCREST AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3680
Practice Address - Country:US
Practice Address - Phone:507-451-0290
Practice Address - Fax:507-451-0291
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND88031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0009974OtherDORAL
MN1009471OtherPREFERRED ONE
MN118128OtherUCARE MN
MN35177NUOtherBLUE CROSS BLUE SHIELD
MN118128OtherUCARE MN