Provider Demographics
NPI:1811523459
Name:GUSTAFSON, KERIN E (DMD)
Entity type:Individual
Prefix:DR
First Name:KERIN
Middle Name:E
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 GENERAL BOOTH BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-5934
Mailing Address - Country:US
Mailing Address - Phone:757-821-7397
Mailing Address - Fax:
Practice Address - Street 1:2204 GENERAL BOOTH BLVD STE 400
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5934
Practice Address - Country:US
Practice Address - Phone:757-821-7397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416946122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist