Provider Demographics
NPI:1124449129
Name:VISEH SUNDBERG DDS PC
Entity type:Organization
Organization Name:VISEH SUNDBERG DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VISEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOVAREKHI-SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-546-9079
Mailing Address - Street 1:222 NW 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3109
Mailing Address - Country:US
Mailing Address - Phone:503-546-9079
Mailing Address - Fax:503-546-5474
Practice Address - Street 1:222 NW 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3109
Practice Address - Country:US
Practice Address - Phone:503-546-9079
Practice Address - Fax:503-546-5474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7735261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7735OtherSTATE BOARD OF DENTISTRY