Provider Demographics
NPI:1316910763
Name:GUSTAFSON, KERRI SUE (DDS)
Entity type:Individual
Prefix:DR
First Name:KERRI
Middle Name:SUE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18245 E 10 MILE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5807
Mailing Address - Country:US
Mailing Address - Phone:586-585-2402
Mailing Address - Fax:586-445-1473
Practice Address - Street 1:18245 E 10 MILE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5807
Practice Address - Country:US
Practice Address - Phone:586-585-2402
Practice Address - Fax:586-445-1473
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD117101223P0221X
MI29010183191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ810645OtherBLUE CROSS BLUE SHIELD
MI4641668Medicaid