Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 19-15094 | IL |
NPI | 1003812579 |
---|---|
Provider Name | Dr. Gary Gustavson |
First Address | Skokie, IL 60077-1440 |
Second Address | Skokie, IL 60077-1440 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2005 |
Last Update Date | 08/07/2007 |