Provider Demographics
NPI:1164489654
Name:GUSTAFSON, MARCUS MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:MICHAEL
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 1:16678 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MN
Mailing Address - Zip Code:55043-9531
Mailing Address - Country:US
Mailing Address - Phone:612-867-6177
Mailing Address - Fax:
Practice Address - Street 1:16678 7TH ST S
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:MN
Practice Address - Zip Code:55043-9531
Practice Address - Country:US
Practice Address - Phone:612-867-6177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND8384122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist