MEDICARE: MELISSA MARKS GUSTAFSON, DDS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	7153	NC

General Provider Information

NPI Number	:	1962936104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MELISSA MARKS GUSTAFSON, DDS, PA

Provider Business Mailing Address
First Line	:	3010 BAUCOM RD STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-6765
Country	:	US
Telephone Number	:	704-596-0021
Fax Number	:	704-599-1155

Provider Business Practice Location Address
First Line	:	3010 BAUCOM RD STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-6765
Country	:	US
Telephone Number	:	704-596-0021
Fax Number	:	704-599-1155

Authorized Official
Title or Position	:	PRACTICE OWNER
Name	:	DR. MELISSA GUSTAFSON
Credential	:	DDS
Telephone Number	:	704-596-0021

Provider Enumeration Date	:	04/14/2017
Last Update Date	:	04/14/2017

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