Provider Demographics
NPI:1568651883
Name:GUSTAFSSON, MATTHEW H (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:H
Last Name:GUSTAFSSON
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Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:11253 BROCKWAY RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-3359
Mailing Address - Country:US
Mailing Address - Phone:530-550-9311
Mailing Address - Fax:530-550-8655
Practice Address - Street 1:11253 BROCKWAY RD
Practice Address - Street 2:SUITE 205
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-3359
Practice Address - Country:US
Practice Address - Phone:530-550-9311
Practice Address - Fax:530-550-8655
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2008-07-21
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Provider Licenses
StateLicense IDTaxonomies
CA555271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry