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General NPI Number Information
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NPI Number | 1316910763
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Entity Type | Individual
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Provider Name | KERRI SUE GUSTAFSON DDS
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Gender | Female
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Dates
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Enumeration Date | 02/08/2006
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Last Update Date | 10/03/2022
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Provider Practice Location Address
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Address Line | 18245 E 10 MILE RD SUITE 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 | 586-445-1473
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Provider Business Mailing Address
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Address Line | 18245 E 10 MILE RD SUITE 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 | 586-445-1473
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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 | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D11710
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2901018319
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License Number State | MI
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