Healthcare Provider Details

I. General information

NPI: 1477720985
Provider Name (Legal Business Name): FREDERICK GUSTAVE, D.D.S., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E WALNUT ST SUITE B
CARBONDALE IL
62901-5000
US

IV. Provider business mailing address

1111 E WALNUT ST SUITE B
CARBONDALE IL
62901-5000
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-2571
  • Fax: 618-529-2572
Mailing address:
  • Phone: 618-529-2571
  • Fax: 618-529-2572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number019016600
License Number StateIL

VIII. Authorized Official

Name: DR. FREDERICK GUSTAVE
Title or Position: OWNER/ORAL SURGEON
Credential: DDS
Phone: 618-529-2571