Provider Demographics
NPI:1902061666
Name:DEREK L GUSTAFSON, D.D.S., P.A.
Entity Type:Organization
Organization Name:DEREK L GUSTAFSON, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-743-3707
Mailing Address - Street 1:100 PINE TREE DR.
Mailing Address - Street 2:PO BOX 14
Mailing Address - City:BIGFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56628-5596
Mailing Address - Country:US
Mailing Address - Phone:218-743-3707
Mailing Address - Fax:
Practice Address - Street 1:100 PINE TREE DR.
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MN
Practice Address - Zip Code:56628-5596
Practice Address - Country:US
Practice Address - Phone:218-743-3707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND123871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty