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General NPI Number Information
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NPI Number | 1114033214
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Entity Type | Individual
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Provider Name | MARK EDWARD GUSTAFSON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 08/22/2006
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Last Update Date | 09/04/2009
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Provider Practice Location Address
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Address Line | 3431 COMMERCE PARKWAY SUITE A
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City | WOOSTER
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State | OH
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Zip | 44691
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Country | US
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Telephone | 330-264-8973
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Fax | 330-262-3072
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Provider Business Mailing Address
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Address Line | 3431 COMMERCE PARKWAY SUITE A
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City | WOOSTER
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State | OH
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Zip | 44691
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Country | US
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Telephone | 330-264-8973
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Fax | 330-262-3072
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30-017218
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30-01-7218
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License Number State | OH
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