Provider Demographics
NPI:1851491310
Name:SUN, DI (DDS PHD)
Entity Type:Individual
Prefix:DR
First Name:DI
Middle Name:
Last Name:SUN
Suffix:
Gender:M
Credentials:DDS PHD
Other - Prefix:DR
Other - First Name:DI
Other - Middle Name:
Other - Last Name:SUN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, PHD
Mailing Address - Street 1:610 PROFESSIONAL DR STE 215
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3439
Mailing Address - Country:US
Mailing Address - Phone:301-869-8666
Mailing Address - Fax:301-869-8677
Practice Address - Street 1:610 PROFESSIONAL DR STE 215
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3439
Practice Address - Country:US
Practice Address - Phone:301-869-8666
Practice Address - Fax:301-869-8677
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD115081223S0112X, 122300000X, 1223P0106X
DC53261223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5486025Medicaid
MD5486025Medicaid
MD490174Medicare ID - Type Unspecified
DC490280Medicare ID - Type Unspecified
DCX36809Medicare UPIN