Provider Demographics
NPI:1508935180
Name:GUSTAFSON, MELISSA MARKS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARKS
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 BAUCOM RD
Mailing Address - Street 2:STE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269
Mailing Address - Country:US
Mailing Address - Phone:704-596-0021
Mailing Address - Fax:
Practice Address - Street 1:3010 BAUCOM RD
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-0983
Practice Address - Country:US
Practice Address - Phone:704-596-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist