Provider Demographics
NPI:1295347805
Name:KERRI S. GUSTAFSON, DDS, PLLC, DENTISTRY FOR CHILDREN
Entity type:Organization
Organization Name:KERRI S. GUSTAFSON, DDS, PLLC, DENTISTRY FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:S
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-917-2215
Mailing Address - Street 1:830 CADIEUX RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1232
Mailing Address - Country:US
Mailing Address - Phone:303-917-2215
Mailing Address - Fax:
Practice Address - Street 1:18245 E 10 MILE RD STE 110
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5807
Practice Address - Country:US
Practice Address - Phone:586-585-2402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KERRI S. GUSTAFSON, DDS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1316910763OtherNPI TYPE 1