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General NPI Number Information
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NPI Number | 1124172150
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Entity Type | Organization
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Legal Business Name | GUNDERSEN DENTAL CARE
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 115 CLEVELAND AVE SE
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City | TUMWATER
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State | WA
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Zip | 98501-7718
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Country | US
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Telephone | 360-352-2781
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Fax |
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Provider Business Mailing Address
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Address Line | 115 CLEVELAND AVE SE
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City | TUMWATER
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State | WA
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Zip | 98501-7718
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Country | US
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Telephone | 360-352-2781
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Fax |
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Authorized Official
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Title or Position | FINANCIAL MANAGER
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Name | ROSE GUNDERSEN
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Credential |
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Telephone | 360-352-2781
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8494
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License Number State | WA
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