Provider Demographics
NPI:1174678320
Name:THOLSTROM, TAD CHRISTIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:TAD
Middle Name:CHRISTIAN
Last Name:THOLSTROM
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 1:48 MDG/SGHC
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09461
Mailing Address - Country:US
Mailing Address - Phone:44148-082-4585
Mailing Address - Fax:
Practice Address - Street 1:48 MDG
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:09461-5115
Practice Address - Country:US
Practice Address - Phone:44148-082-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9214122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9214OtherDENTAL LICENSE