Provider Demographics
NPI:1205148145
Name:GUSTAFSON, AIMEE JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:AIMEE
Middle Name:JEAN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:AIMEE
Other - Middle Name:JEAN
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-0880
Mailing Address - Country:US
Mailing Address - Phone:406-745-3525
Mailing Address - Fax:
Practice Address - Street 1:5 4TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2117
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT24851223G0001X
MTDEN-DEN-LIC-2485122300000X
MND12841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7097623Medicaid
MT271810Medicare PIN