Provider Demographics
NPI:1942588439
Name:GUSTAFSON, AMY KRISTINA LEE (DMD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KRISTINA LEE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:K
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:123 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-4200
Mailing Address - Country:US
Mailing Address - Phone:406-247-3333
Mailing Address - Fax:
Practice Address - Street 1:123 S 27TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-4200
Practice Address - Country:US
Practice Address - Phone:406-247-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT24731223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health