Basic Information
| Provider Information | |||||||||
| NPI: | 1205148145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | AIMEE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARR | ||||||||
| OtherFirstName: | AIMEE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 308 MISSION DR | ||||||||
| Address2: | |||||||||
| City: | ST IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598659676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 102 1ST AVE E | ||||||||
| Address2: | |||||||||
| City: | POLSON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598602335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453524 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2485 | MT | Y | Dental Providers | Dentist | 122300000X | D12841 | MN | N | Dental Providers | Dentist | 1223G0001X | 2485 | MT | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 7097623 | 05 | MT | MEDICAID |