Active NPI
Gary Gustavson, D.D.S.
- Dentist
- Skokie, IL
National Provider Identifier
1003812579
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 19-15094
- Practice address
- 64 Old Orchard Ctr
Ste 528
Skokie, IL 60077-1440 - Phone
- (847) 675-3311
- NPI assigned
- Jun 21, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 19-15094 | IL | Primary |
Addresses
Primary practice location
64 Old Orchard Ctr
Ste 528
Skokie, IL 60077-1440
Mailing address
64 Old Orchard Ctr
Ste 528
Skokie, IL 60077-1440
Phone (847) 675-3311
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 19-15094 | IL | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1119312000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1003812579",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "64 OLD ORCHARD CTR",
"address_2": "STE 528",
"city": "SKOKIE",
"state": "IL",
"postal_code": "600771440",
"telephone_number": "847-675-3311"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "64 OLD ORCHARD CTR",
"address_2": "STE 528",
"city": "SKOKIE",
"state": "IL",
"postal_code": "600771440",
"telephone_number": "847-675-3311"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GUSTAVSON",
"first_name": "GARY",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-06-21",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": "19-15094",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Skokie, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.