| Doctor Name: | MR. RYAN R GUSTAFSON |
| NPI Number: | 1376816462 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.D.S |
| License Number: | |
| Business Practice Address: | 90 Vandenberg Dr 66 Mds (afmc) Hanscom Afb, MA - 017312104 |
| Business Phone Number: | 7812256789 |
| Business Fax Number: | 7812252561 |
| Mailing Address: | 90 Vandenberg Dr, 66 Mds (afmc) HANSCOM AFB |
| State: | MA |
| Postal Code: | 017312104 |
| Phone Number: | 7812256789 |
| Fax Number: | 7812252561 |
| NPI Enumeration Date: | 02/20/2012 |
| NPI Last Update Date: | 01/14/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |