Provider Demographics
NPI:1558928655
Name:SUTHERLAND, IAN THOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:THOR
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 9TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-3433
Mailing Address - Country:US
Mailing Address - Phone:330-354-6250
Mailing Address - Fax:
Practice Address - Street 1:2133 PEPPERRELL ST
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5313
Practice Address - Country:US
Practice Address - Phone:330-354-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
390200000X
MTDEN-DEN-LIC-19483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program