Provider Demographics
NPI:1518124312
Name:GUSTAFSON & MORNINGSTAR DDS PC
Entity Type:Organization
Organization Name:GUSTAFSON & MORNINGSTAR DDS PC
Other - Org Name:GUSTAFSON MORNINGSTAR DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-541-8770
Mailing Address - Street 1:940 E 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1968
Mailing Address - Country:US
Mailing Address - Phone:248-541-8770
Mailing Address - Fax:248-546-7794
Practice Address - Street 1:940 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1968
Practice Address - Country:US
Practice Address - Phone:248-541-8770
Practice Address - Fax:248-546-7794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI138971223G0001X
MI139011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty