Provider Demographics
NPI:1730798331
Name:GASTELUM, JOSSEN P (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSSEN
Middle Name:P
Last Name:GASTELUM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12090 N THORNYDALE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85658-4779
Mailing Address - Country:US
Mailing Address - Phone:520-616-4610
Mailing Address - Fax:
Practice Address - Street 1:12090 N THORNYDALE RD STE 106
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85658-4779
Practice Address - Country:US
Practice Address - Phone:520-616-4610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104791223G0001X
AZD0108621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice