Provider Demographics
NPI:1851959563
Name:SUN, NINGYUAN
Entity Type:Individual
Prefix:
First Name:NINGYUAN
Middle Name:
Last Name:SUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 STEVENS AVE OFC 303
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2666
Mailing Address - Country:US
Mailing Address - Phone:617-690-9572
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2617
Practice Address - Country:US
Practice Address - Phone:207-221-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN49971223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics