MEDICARE: DR. JEFFREY SUNDBERG D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5001409	WI

General Provider Information

NPI Number	:	1518072735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY SUNDBERG D.D.S.

Provider Business Mailing Address
First Line	:	713 MAPLE CREST LN
Second Line	:
City	:	WATERTOWN
State	:	WI
Zip	:	53094-6015
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1508 DOCTORS CT
Second Line	:
City	:	WATERTOWN
State	:	WI
Zip	:	53094-4102
Country	:	US
Telephone Number	:	920-261-1566
Fax Number	:	920-261-5537

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/08/2007

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