Provider Demographics
NPI:1598957748
Name:GUSTIN, ALLEN NATHANIEL (DDS)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:NATHANIEL
Last Name:GUSTIN
Suffix:
Gender:M
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:PO BOX 402
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-0027
Mailing Address - Country:US
Mailing Address - Phone:843-549-1215
Mailing Address - Fax:843-549-1835
Practice Address - Street 1:113 MAGNOLIA STREET
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-0027
Practice Address - Country:US
Practice Address - Phone:843-549-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1532122300000X
VA3851122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist