Provider Demographics
NPI:1326358995
Name:MARK A. SUNDBERG, DDS, PLLC
Entity Type:Organization
Organization Name:MARK A. SUNDBERG, DDS, PLLC
Other - Org Name:PACIFIC NORTHWEST ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-472-7788
Mailing Address - Street 1:2702 SOUTH 42ND STREET
Mailing Address - Street 2:SUITE 106
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409
Mailing Address - Country:US
Mailing Address - Phone:253-472-7788
Mailing Address - Fax:
Practice Address - Street 1:2702 SOUTH 42ND STREET
Practice Address - Street 2:SUITE 106
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409
Practice Address - Country:US
Practice Address - Phone:253-472-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000105041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty