Provider Demographics
NPI:1699804880
Name:SUNDBERG, MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:SUNDBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 FOREST AVE
Mailing Address - Street 2:PORTLAND FAMILY DENTAL
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3343
Mailing Address - Country:US
Mailing Address - Phone:207-797-3585
Mailing Address - Fax:207-797-3592
Practice Address - Street 1:1006 FOREST AVE
Practice Address - Street 2:PORTLAND FAMILY DENTAL
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3343
Practice Address - Country:US
Practice Address - Phone:207-797-3585
Practice Address - Fax:207-797-3592
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice