Provider Demographics
NPI:1598337982
Name:GUSTAFSON, CARSON LEIGH (DDS)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:LEIGH
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CARSON
Other - Middle Name:LEIGH
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:695 ALTAIR DR
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80124-2501
Mailing Address - Country:US
Mailing Address - Phone:417-293-7221
Mailing Address - Fax:
Practice Address - Street 1:8545 E ARAPAHOE RD UNIT A
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80112-1476
Practice Address - Country:US
Practice Address - Phone:509-289-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611874831223G0001X
CODEN.002052661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice