Provider Demographics
NPI:1245226752
Name:GUSTAFSON, RYLAN
Entity type:Individual
Prefix:
First Name:RYLAN
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RALEY BLVD
Mailing Address - Street 2:STE 202
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-8352
Mailing Address - Country:US
Mailing Address - Phone:530-592-4688
Mailing Address - Fax:
Practice Address - Street 1:101 RALEY BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-8352
Practice Address - Country:US
Practice Address - Phone:530-592-4688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA575931223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics