Provider Demographics
NPI:1568536845
Name:SUNDBERG, KERI LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KERI
Middle Name:LYNN
Last Name:SUNDBERG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 PLAZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342
Mailing Address - Country:US
Mailing Address - Phone:815-539-7004
Mailing Address - Fax:815-539-7060
Practice Address - Street 1:WEST SIDE FAMILY DENTISTRY, LTD.
Practice Address - Street 2:709 PLAZA DRIVE
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342
Practice Address - Country:US
Practice Address - Phone:815-539-7004
Practice Address - Fax:815-539-7060
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190255311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice