Provider Demographics
NPI:1356326029
Name:GUSTAFSON, DEREK L (DDS)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:L
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 1:2467 15TH ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5596
Mailing Address - Country:US
Mailing Address - Phone:651-633-4883
Mailing Address - Fax:651-633-4998
Practice Address - Street 1:2467 15TH ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-5596
Practice Address - Country:US
Practice Address - Phone:651-633-4883
Practice Address - Fax:651-633-4998
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2591122300000X
MN123871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DD2591OtherDENTAL LICENSE
MN12387OtherLICENSE