Provider Demographics
NPI:1619425956
Name:SUNDIN, KATHY
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:SUNDIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:ANNE
Other - Last Name:SUNDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1283 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-5587
Mailing Address - Country:US
Mailing Address - Phone:360-263-4189
Mailing Address - Fax:
Practice Address - Street 1:1201 SE TECH CENTER DR STE 150
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5523
Practice Address - Country:US
Practice Address - Phone:360-892-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH 60056765124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist