Provider Demographics
NPI:1396759932
Name:GUSTAFSON, DUANE BROWER (DMD)
Entity type:Individual
Prefix:DR
First Name:DUANE
Middle Name:BROWER
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 WOODSIDE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-3402
Mailing Address - Country:US
Mailing Address - Phone:650-369-2555
Mailing Address - Fax:650-369-2556
Practice Address - Street 1:1690 WOODSIDE RD STE 209
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-3402
Practice Address - Country:US
Practice Address - Phone:650-369-2555
Practice Address - Fax:650-369-2556
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist