Provider Demographics
NPI:1457431025
Name:GUSTAVSEN, ERIC ROSS (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ROSS
Last Name:GUSTAVSEN
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 1:1129 SOUTH 2ND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-522-2522
Mailing Address - Fax:509-522-0467
Practice Address - Street 1:1129 SOUTH 2ND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-522-2522
Practice Address - Fax:509-522-0467
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000080371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA58037OtherWASHINGTON DENTAL