Healthcare Provider Details

I. General information

NPI: 1851491310
Provider Name (Legal Business Name): DI SUN DDS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DI SUN DDS, PHD

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 PROFESSIONAL DR STE 215
GAITHERSBURG MD
20879-3439
US

IV. Provider business mailing address

610 PROFESSIONAL DR STE 215
GAITHERSBURG MD
20879-3439
US

V. Phone/Fax

Practice location:
  • Phone: 301-869-8666
  • Fax: 301-869-8677
Mailing address:
  • Phone: 301-869-8666
  • Fax: 301-869-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11508
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number11508
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number5326
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number11508
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5326
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: