Healthcare Provider Details

I. General information

NPI: 1750437380
Provider Name (Legal Business Name): ROLAND BRANT GUSTAFSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6238 YELLOWSTONE RD
CHEYENNE WY
82009-3432
US

IV. Provider business mailing address

6238 YELLOWSTONE RD
CHEYENNE WY
82009-3432
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-6940
  • Fax: 307-635-2839
Mailing address:
  • Phone: 307-635-6940
  • Fax: 307-635-2839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1054
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: