Provider Demographics
NPI:1366533564
Name:GUSTAFSON, JOHN VICTOR (DMD,MAGD,FADI)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VICTOR
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DMD,MAGD,FADI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-2019
Mailing Address - Country:US
Mailing Address - Phone:717-367-1560
Mailing Address - Fax:717-367-8856
Practice Address - Street 1:102 W HIGH ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2019
Practice Address - Country:US
Practice Address - Phone:717-367-1560
Practice Address - Fax:717-367-8856
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-02849-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice