Gustafson, Derek L

Gustafson, Derek L is an sole proprietor health care provider with primary practice located at 2467 15Th St Nw Suite A, New Brighton MN 55112-5596. He recently has 2 registered licenses in different health care specialties including Dental Providers / Dentist, Dental Providers / General Practice. Dental Providers / General Practice is his primary health care specialty. Gustafson, Derek L can be contacted via phone (651) 633-4883.

Contact Information

Primary practice address
2467 15Th St Nw Suite A New Brighton MN 55112-5596
Phone: (651) 633-4883
Fax: (651) 633-4998
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Dental Providers / Dentist 122300000X DD2591 New Mexico
Dental Providers / General Practice 1223G0001X 12387 Minnesota

Profile Details

NPI number 1356326029
LBN Legal business name Gustafson, Derek L
Credentials Doctor of Dental Surgery (DDS)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Dec 14th, 2005
Last updated Jul 23rd, 2008 - about 17 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1356326029 NPPES
Other DD2591 DENTAL LICENSE
Other 12387 DENTAL LICENSE

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