Provider Demographics
NPI:1114470432
Name:GUNDERSEN DENTAL, PLLC
Entity Type:Organization
Organization Name:GUNDERSEN DENTAL, PLLC
Other - Org Name:TYLER B. GUNDERSEN, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:GUNDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-663-4436
Mailing Address - Street 1:251 N. CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801
Mailing Address - Country:US
Mailing Address - Phone:509-663-4436
Mailing Address - Fax:509-663-5974
Practice Address - Street 1:251 N. CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801
Practice Address - Country:US
Practice Address - Phone:509-663-4436
Practice Address - Fax:509-663-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X
WADE00010222261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048871Medicaid