Provider Demographics
NPI:1003181223
Name:VISEH SUNDBERG DDS PC
Entity Type:Organization
Organization Name:VISEH SUNDBERG DDS PC
Other - Org Name:SUNDBERG CENTER FOR DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JON
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:503-546-9079
Mailing Address - Street 1:222 NW 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3109
Mailing Address - Country:US
Mailing Address - Phone:503-546-9079
Mailing Address - Fax:503-546-5474
Practice Address - Street 1:222 NW 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3109
Practice Address - Country:US
Practice Address - Phone:503-546-9079
Practice Address - Fax:503-546-5474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty