Provider Demographics
NPI:1801832647
Name:GUSTAFSON, WILLIAM E (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:E
Last Name:GUSTAFSON
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:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633-0349
Mailing Address - Country:US
Mailing Address - Phone:864-654-5733
Mailing Address - Fax:864-654-1117
Practice Address - Street 1:875 OLD CLEMSON HWY
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-8060
Practice Address - Country:US
Practice Address - Phone:864-654-5733
Practice Address - Fax:864-654-1117
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1738122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2X1738Medicaid