Basic Information
| Provider Information | |||||||||
| NPI: | 1659045540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | ERIK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15303 W BAYAUD CT | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804016562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035184677 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12600 W COLFAX AVE STE B160 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802153754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032370307 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DEN.00204811 | CO | Y | Dental Providers | Dentist | General Practice |
No ID Information.