1356326029 NPI number — DEREK L GUSTAFSON DDS

Table of content: DEREK L GUSTAFSON DDS (NPI 1356326029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356326029 NPI number — DEREK L GUSTAFSON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTAFSON
Provider First Name:
DEREK
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356326029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2467 15TH ST NW
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-5596
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-633-4883
Provider Business Mailing Address Fax Number:
651-633-4998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2467 15TH ST NW
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NEW BRIGHTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55112-5596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-633-4883
Provider Business Practice Location Address Fax Number:
651-633-4998
Provider Enumeration Date:
12/14/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DD2591 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 12387 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DD2591 . This is a "DENTAL LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12387 . This is a "LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".