Provider Demographics
NPI:1659340503
Name:WITTENSTROM, JOHN CARLTON (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CARLTON
Last Name:WITTENSTROM
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 1:14990 GLAZIER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7819
Mailing Address - Country:US
Mailing Address - Phone:952-431-5114
Mailing Address - Fax:
Practice Address - Street 1:14990 GLAZIER AVE STE 100
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7819
Practice Address - Country:US
Practice Address - Phone:612-861-9123
Practice Address - Fax:612-861-9155
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND100821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice