NPIMap

Organization Active NPI

Melissa Marks Gustafson, DDS, PA

  • Dental Clinic/Center
  • Charlotte, NC
National Provider Identifier
1962936104
Registry record updated Apr 14, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
License
7153 Issued in NC
Legal business name
MELISSA MARKS GUSTAFSON, DDS, PA
Practice address
3010 Baucom Rd Ste 200
Charlotte, NC 28269-6765
Phone
(704) 596-0021
Fax
(704) 599-1155
NPI assigned
Apr 14, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 14, 2017

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

Authorized official

Name
Dr. Melissa Gustafson, DDS
Title
Practice Owner
Phone
(704) 596-0021

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X 7153 NC Primary

Addresses

Primary practice location

3010 Baucom Rd Ste 200
Charlotte, NC 28269-6765

Mailing address

3010 Baucom Rd Ste 200
Charlotte, NC 28269-6765
Phone (704) 596-0021

Other names 1

  • Mallard Creek Family Dentistry Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Mallard Creek Family Dentistry2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3010 Baucom Rd
Ste 200
Charlotte, NC 28269
Phone (704) 596-0021

NPI Registry JSON

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

{
    "created_epoch": "1492128000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1492128000000",
    "number": "1962936104",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3010 BAUCOM RD STE 200",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282696765",
            "telephone_number": "704-596-0021",
            "fax_number": "704-599-1155"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3010 BAUCOM RD STE 200",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282696765",
            "telephone_number": "704-596-0021",
            "fax_number": "704-599-1155"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MELISSA MARKS GUSTAFSON, DDS, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-04-14",
        "last_updated": "2017-04-14",
        "status": "A",
        "authorized_official_last_name": "GUSTAFSON",
        "authorized_official_first_name": "MELISSA",
        "authorized_official_title_or_position": "PRACTICE OWNER",
        "authorized_official_telephone_number": "704-596-0021",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "NC",
            "license": "7153",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mallard Creek Family Dentistry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charlotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2017; 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.