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General NPI Number Information
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NPI Number | 1295347805
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Entity Type | Organization
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Legal Business Name | KERRI S. GUSTAFSON, DDS, PLLC, DENTISTRY FOR CHILDREN
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Dates
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Enumeration Date | 08/17/2020
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Last Update Date | 08/17/2020
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Provider Practice Location Address
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Address Line | 18245 E 10 MILE RD STE 110
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City | ROSEVILLE
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State | MI
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Zip | 48066-5807
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Country | US
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Telephone | 586-585-2402
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Fax |
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Provider Business Mailing Address
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Address Line | 830 CADIEUX RD
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City | GROSSE POINTE
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State | MI
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Zip | 48230-1232
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Country | US
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Telephone | 303-917-2215
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Fax |
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Authorized Official
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Title or Position | DDS, OWNER
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Name | DR. KERRI S GUSTAFSON
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Credential | DDS
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Telephone | 303-917-2215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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