Provider Demographics
NPI:1306100011
Name:GUSTAFSON, CHAD MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:MICHAEL
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 1:100 ALBERU ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-2543
Mailing Address - Country:US
Mailing Address - Phone:985-290-9558
Mailing Address - Fax:
Practice Address - Street 1:925 CROSS GATES BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-3920
Practice Address - Country:US
Practice Address - Phone:985-646-1726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA63141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice