Provider Demographics
NPI:1164514402
Name:SUDBRINK, STEVEN D (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:D
Last Name:SUDBRINK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20726 SABAL ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32833-5624
Mailing Address - Country:US
Mailing Address - Phone:717-314-6969
Mailing Address - Fax:
Practice Address - Street 1:800 GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1635
Practice Address - Country:US
Practice Address - Phone:717-733-8645
Practice Address - Fax:717-733-9172
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS028494L1223S0112X, 204E00000X
FLDN244041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U42077Medicare UPIN
PA090166Medicare PIN