Provider Demographics
NPI:1376816462
Name:GUSTAFSON, RYAN R (DDS)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:R
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 1:90 VANDENBERG DR
Mailing Address - Street 2:66 MDS (AFMC)
Mailing Address - City:HANSCOM AFB
Mailing Address - State:MA
Mailing Address - Zip Code:01731-2104
Mailing Address - Country:US
Mailing Address - Phone:781-225-6789
Mailing Address - Fax:781-225-2561
Practice Address - Street 1:90 VANDENBERG DR
Practice Address - Street 2:66 MDS (AFMC)
Practice Address - City:HANSCOM AFB
Practice Address - State:MA
Practice Address - Zip Code:01731-2104
Practice Address - Country:US
Practice Address - Phone:781-225-6789
Practice Address - Fax:781-225-2561
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA61707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program