Provider Demographics
NPI:1770664310
Name:SUTHERLAND, GREG W (DDS, MS, PS)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:W
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:DDS, MS, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-5863
Mailing Address - Country:US
Mailing Address - Phone:253-848-4537
Mailing Address - Fax:253-841-0792
Practice Address - Street 1:210 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-5863
Practice Address - Country:US
Practice Address - Phone:253-848-4537
Practice Address - Fax:253-841-0792
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025103DE00048011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics