Provider Demographics
NPI:1477118503
Name:JOHN S. SUTHERLAND DDS ,INC
Entity Type:Organization
Organization Name:JOHN S. SUTHERLAND DDS ,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANDEL
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:206-718-5656
Mailing Address - Street 1:705 RIVERCREST PKWY
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-3544
Mailing Address - Country:US
Mailing Address - Phone:530-222-4951
Mailing Address - Fax:
Practice Address - Street 1:3855 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-3229
Practice Address - Country:US
Practice Address - Phone:530-243-9425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306127915OtherMARK LEWIS
CA1396924437OtherJOHN SUTHERLAND