Provider Demographics
NPI:1891709168
Name:GUSTAVE, FREDERICK (DDS)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:GUSTAVE
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 1:10200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-1408
Mailing Address - Country:US
Mailing Address - Phone:618-400-6725
Mailing Address - Fax:618-500-6725
Practice Address - Street 1:10200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-1408
Practice Address - Country:US
Practice Address - Phone:618-400-6725
Practice Address - Fax:618-500-6725
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190166001223S0112X
IL0210010981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL654820Medicare ID - Type Unspecified