Provider Demographics
NPI:1124172150
Name:GUNDERSEN DENTAL CARE
Entity type:Organization
Organization Name:GUNDERSEN DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-352-2781
Mailing Address - Street 1:115 CLEVELAND AVE SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-7718
Mailing Address - Country:US
Mailing Address - Phone:360-352-2781
Mailing Address - Fax:
Practice Address - Street 1:115 CLEVELAND AVE SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-7718
Practice Address - Country:US
Practice Address - Phone:360-352-2781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty