Provider Demographics
NPI:1962490144
Name:OSTROM, THEODOR ELMOND (DDS)
Entity Type:Individual
Prefix:
First Name:THEODOR
Middle Name:ELMOND
Last Name:OSTROM
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 1:1145 WILLOW BEND CIR APT 2
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-7035
Mailing Address - Country:US
Mailing Address - Phone:719-594-2050
Mailing Address - Fax:
Practice Address - Street 1:1145 WILLOW BEND CIR. #2
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-7035
Practice Address - Country:US
Practice Address - Phone:719-594-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice