Individual
DEREK L GUSTAFSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2467 15TH ST NW, SUITE A, NEW BRIGHTON, MN 55112-5596
(651) 633-4883
(651) 633-4998
Mailing address
2467 15TH ST NW, SUITE A, NEW BRIGHTON, MN 55112-5596
(651) 633-4883
(651) 633-4998
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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