Active NPI
Derek L Gustafson, DDS
- General Practice Dentistry
- New Brighton, MN
National Provider Identifier
1356326029
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 12387
- Practice address
- 2467 15TH St NW
Suite a
New Brighton, MN 55112-5596 - Phone
- (651) 633-4883
- Fax
- (651) 633-4998
- NPI assigned
- Dec 14, 2005
- Last updated
- Jul 23, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DD2591 | NM | |
| General Practice Dentistry | 1223G0001X | 12387 | MN | Primary |
Addresses
Primary practice location
2467 15TH St NW
Suite a
New Brighton, MN 55112-5596
Mailing address
2467 15TH St NW
Suite a
New Brighton, MN 55112-5596
Phone (651) 633-4883
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| DD2591 | Other | DENTAL LICENSE | |
| 12387 | Other | MN | LICENSE |
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 |
|---|---|---|---|
| DD2591 | NM | MD | Dentist |
| 12387 | MN | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Dr My Pang Kou Vang DDS, PLLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Dental Clinic/Center
- New Brighton, MN
- NPI 1174419923
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1134518400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1216771200000",
"number": "1356326029",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2467 15TH ST NW",
"address_2": "SUITE A",
"city": "NEW BRIGHTON",
"state": "MN",
"postal_code": "551125596",
"telephone_number": "651-633-4883",
"fax_number": "651-633-4998"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2467 15TH ST NW",
"address_2": "SUITE A",
"city": "NEW BRIGHTON",
"state": "MN",
"postal_code": "551125596",
"telephone_number": "651-633-4883",
"fax_number": "651-633-4998"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GUSTAFSON",
"first_name": "DEREK",
"middle_name": "L",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-12-14",
"last_updated": "2008-07-23",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NM",
"license": "DD2591",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MN",
"license": "12387",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DENTAL LICENSE",
"identifier": "DD2591",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICENSE",
"identifier": "12387",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in New Brighton, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.