Provider Demographics
NPI:1841404910
Name:SUNSTROM, JON LESLIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:LESLIE
Last Name:SUNSTROM
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 1:708 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-2726
Mailing Address - Country:US
Mailing Address - Phone:515-432-4223
Mailing Address - Fax:515-432-1054
Practice Address - Street 1:708 8TH ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-2726
Practice Address - Country:US
Practice Address - Phone:515-432-4223
Practice Address - Fax:515-432-1054
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA65791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0173963Medicaid
IA173963OtherDELTA DENTAL INSURANCE