Provider Demographics
NPI:1659888105
Name:GUNN, SHERRY LANE
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:LANE
Last Name:GUNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6403 BRANDO LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3764
Mailing Address - Country:US
Mailing Address - Phone:916-969-5853
Mailing Address - Fax:
Practice Address - Street 1:555 FREMONT ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2534
Practice Address - Country:US
Practice Address - Phone:530-458-8635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21451124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist