Healthcare Provider Details

I. General information

NPI: 1942588439
Provider Name (Legal Business Name): AMY KRISTINA LEE GUSTAFSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY K THOMPSON

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S 27TH ST
BILLINGS MT
59101-4200
US

IV. Provider business mailing address

123 S 27TH ST
BILLINGS MT
59101-4200
US

V. Phone/Fax

Practice location:
  • Phone: 406-247-3333
  • Fax:
Mailing address:
  • Phone: 406-247-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2473
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: