Healthcare Provider Details

I. General information

NPI: 1205148145
Provider Name (Legal Business Name): AIMEE JEAN GUSTAFSON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AIMEE JEAN CARR

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 4TH AVE E
POLSON MT
59860-2117
US

IV. Provider business mailing address

PO BOX 880
SAINT IGNATIUS MT
59865-0880
US

V. Phone/Fax

Practice location:
  • Phone: 406-745-3525
  • Fax:
Mailing address:
  • Phone: 406-745-3525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN-DEN-LIC-2485
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12841
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2485
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: