Provider Demographics
NPI:1114033214
Name:GUSTAFSON, MARK EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:GUSTAFSON
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 1:3431 COMMERCE PARKWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691
Mailing Address - Country:US
Mailing Address - Phone:330-264-8973
Mailing Address - Fax:330-262-3072
Practice Address - Street 1:3431 COMMERCE PARKWAY
Practice Address - Street 2:SUITE A
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691
Practice Address - Country:US
Practice Address - Phone:330-264-8973
Practice Address - Fax:330-262-3072
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0172181223G0001X
OH30-01-72181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0518836Medicaid