Provider Demographics
NPI:1942285275
Name:SUNDIN, ALLAN CARL (DDS)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:CARL
Last Name:SUNDIN
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 1:401 49TH ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-2416
Mailing Address - Country:US
Mailing Address - Phone:757-428-1044
Mailing Address - Fax:
Practice Address - Street 1:1385 LASKIN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6079
Practice Address - Country:US
Practice Address - Phone:757-425-1547
Practice Address - Fax:757-425-6603
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004026122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4964OtherDORAL DENTAL
NC8998188Medicaid