Mark Edward Gustafson, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

30-01-7218 Issued in OH

Practice address

3431 Commerce Parkway
Suite a
Wooster, OH 44691

Phone

(330) 264-8973

Fax

(330) 262-3072

NPI assigned

Aug 22, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156204800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1252022400000",
    "number": "1114033214",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3431 COMMERCE PARKWAY",
            "address_2": "SUITE A",
            "city": "WOOSTER",
            "state": "OH",
            "postal_code": "44691",
            "telephone_number": "330-264-8973",
            "fax_number": "330-262-3072"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3431 COMMERCE PARKWAY",
            "address_2": "SUITE A",
            "city": "WOOSTER",
            "state": "OH",
            "postal_code": "44691",
            "telephone_number": "330-264-8973",
            "fax_number": "330-262-3072"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GUSTAFSON",
        "first_name": "MARK",
        "middle_name": "EDWARD",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-08-22",
        "last_updated": "2009-09-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "OH",
            "license": "30-017218",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "OH",
            "license": "30-01-7218",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0518836",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Paul M Grywalski
• Angela Marie Grywalsky, BA, LSW
• Guadalupe Wooster
• Michaela Gubics
• Tatiana Gurevich, M.D.
• Amy Guthrie
• Daniela Ayleen Gutierrez Carrera
• Richard Guttman, MD
• Melinda Haag, OTR
• Christy L Haagen, CRNP

• General Practice Dentistry in Wooster, OH
• Providers in Wooster, OH by specialty
• General Practice Dentistry in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 4, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.