Provider Demographics
NPI:1063581635
Name:GUSTAVSON, DAN (DDS)
Entity type:Individual
Prefix:MR
First Name:DAN
Middle Name:
Last Name:GUSTAVSON
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 1:1240 HIGH ST UNIT 102
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-5072
Mailing Address - Country:US
Mailing Address - Phone:530-530-3333
Mailing Address - Fax:530-889-9946
Practice Address - Street 1:1240 HIGH ST UNIT 102
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-5072
Practice Address - Country:US
Practice Address - Phone:530-830-3333
Practice Address - Fax:530-889-9946
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice