Basic Information
| Provider Information | |||||||||
| NPI: | 1366412058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUNDBERG | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS, ABGD, MAGD | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 9900, 2ND FLOOR | ||||||||
| Address2: | U.S. ARMY DENTAL ACTIVITY - FT LEWIS | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684039 | ||||||||
| FaxNumber: | 2539685919 | ||||||||
| Practice Location | |||||||||
| Address1: | BLDG 9900, 2ND FLOOR | ||||||||
| Address2: | U.S. ARMY DENTAL ACTIVITY - FT LEWIS | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684039 | ||||||||
| FaxNumber: | 2539685919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 06999 | IA | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.