Provider Demographics
NPI:1477720985
Name:FREDERICK GUSTAVE, D.D.S., PC
Entity Type:Organization
Organization Name:FREDERICK GUSTAVE, D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAVE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:618-529-2571
Mailing Address - Street 1:1111 E WALNUT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5000
Mailing Address - Country:US
Mailing Address - Phone:618-529-2571
Mailing Address - Fax:618-529-2572
Practice Address - Street 1:1111 E WALNUT ST
Practice Address - Street 2:SUITE B
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5000
Practice Address - Country:US
Practice Address - Phone:618-529-2571
Practice Address - Fax:618-529-2572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019016600261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL654820Medicare PIN