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Individual
DEREK L GUSTAFSON
Active
Individual
DEREK L GUSTAFSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
DD2591
NM
1223G0001X
General Practice Dentistry
Primary
12387
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12387
LICENSE
MN
01
—
DD2591
DENTAL LICENSE
—
Enumeration date
12/14/2005
Last updated
07/23/2008
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