1114470432 NPI number — GUNDERSEN DENTAL, PLLC

Table of content: EVELYN ALACANTARA SEVILLA MD (NPI 1720017387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114470432 NPI number — GUNDERSEN DENTAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUNDERSEN DENTAL, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114470432
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 N. CHELAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WENATCHEE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-663-4436
Provider Business Mailing Address Fax Number:
509-663-5974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 N. CHELAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WENATCHEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-663-4436
Provider Business Practice Location Address Fax Number:
509-663-5974
Provider Enumeration Date:
08/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GUNDERSEN
Authorized Official First Name:
TYLER
Authorized Official Middle Name:
BURTON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-663-4436

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QD0000X , with the licence number: DE00010222 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5048871 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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