Healthcare Provider Details

I. General information

NPI: 1114470432
Provider Name (Legal Business Name): GUNDERSEN DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N. CHELAN AVE
WENATCHEE WA
98801
US

IV. Provider business mailing address

251 N. CHELAN AVE
WENATCHEE WA
98801
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-4436
  • Fax: 509-663-5974
Mailing address:
  • Phone: 509-663-4436
  • Fax: 509-663-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDE00010222
License Number StateWA

VIII. Authorized Official

Name: DR. TYLER BURTON GUNDERSEN
Title or Position: OWNER
Credential: D.D.S.
Phone: 509-663-4436