Provider Demographics
NPI:1649339482
Name:GUNDERSON, JAMES SELMER (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:SELMER
Last Name:GUNDERSON
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 1:635 COLBERT ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5421
Mailing Address - Country:US
Mailing Address - Phone:985-674-9274
Mailing Address - Fax:
Practice Address - Street 1:635 COLBERT ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-5421
Practice Address - Country:US
Practice Address - Phone:985-674-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA054441223G0001X
MND114151223G0001X
LA52941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice