Provider Demographics
NPI:1063658466
Name:GUSTAFSON, KAVIN (DDS)
Entity type:Individual
Prefix:
First Name:KAVIN
Middle Name:
Last Name:GUSTAFSON
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:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:AVENAL
Practice Address - State:CA
Practice Address - Zip Code:93204-1850
Practice Address - Country:US
Practice Address - Phone:559-386-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57925122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist