1366412058 NPI number — DR. MARK ALAN SUNDBERG DDS, ABGD, MAGD

Table of content: NIKOLETTE AMOROS (NPI 1215881081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366412058 NPI number — DR. MARK ALAN SUNDBERG DDS, ABGD, MAGD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUNDBERG
Provider First Name:
MARK
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, ABGD, MAGD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1366412058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BLDG 9900, 2ND FLOOR
Provider Second Line Business Mailing Address:
U.S. ARMY DENTAL ACTIVITY - FT LEWIS
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98431-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-968-4039
Provider Business Mailing Address Fax Number:
253-968-5919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLDG 9900, 2ND FLOOR
Provider Second Line Business Practice Location Address:
U.S. ARMY DENTAL ACTIVITY - FT LEWIS
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-4039
Provider Business Practice Location Address Fax Number:
253-968-5919
Provider Enumeration Date:
01/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  06999 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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