Provider Demographics
NPI:1144559162
Name:MATTHEW H. GUSTAFSSON D.D.S., INC.
Entity type:Organization
Organization Name:MATTHEW H. GUSTAFSSON D.D.S., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-550-9311
Mailing Address - Street 1:11149 BROCKWAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-2212
Mailing Address - Country:US
Mailing Address - Phone:530-550-9311
Mailing Address - Fax:530-550-8655
Practice Address - Street 1:11149 BROCKWAY RD STE 100
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-2212
Practice Address - Country:US
Practice Address - Phone:530-550-9311
Practice Address - Fax:530-550-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty