Provider Demographics
NPI:1760737647
Name:DR. JOHN D. GUSTAFSON, D.D.S., PA
Entity Type:Organization
Organization Name:DR. JOHN D. GUSTAFSON, D.D.S., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:507-964-2705
Mailing Address - Street 1:PO BOX 352
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55307
Mailing Address - Country:US
Mailing Address - Phone:507-964-2705
Mailing Address - Fax:507-964-5848
Practice Address - Street 1:106 THIRD AVENUE NW
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MN
Practice Address - Zip Code:55307
Practice Address - Country:US
Practice Address - Phone:507-964-2705
Practice Address - Fax:507-964-5848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty