Provider Demographics
NPI:1205584307
Name:JAMES ROSTVOLD
Entity type:Organization
Organization Name:JAMES ROSTVOLD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT DESK
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LDA
Authorized Official - Phone:218-326-2560
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-0339
Mailing Address - Country:US
Mailing Address - Phone:218-326-2560
Mailing Address - Fax:218-326-8256
Practice Address - Street 1:1043 E US HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3165
Practice Address - Country:US
Practice Address - Phone:218-326-2560
Practice Address - Fax:218-326-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN872720100Medicaid