Provider Demographics
NPI:1962124834
Name:GUNDERSON, DEAN EMMETT
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:EMMETT
Last Name:GUNDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 9TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1830
Mailing Address - Country:US
Mailing Address - Phone:701-361-9922
Mailing Address - Fax:701-829-7140
Practice Address - Street 1:921 2ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1705
Practice Address - Country:US
Practice Address - Phone:701-361-9922
Practice Address - Fax:701-829-7140
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND00000172A00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND171M00000XMedicaid
ND172A00000XMedicaid
ND251B00000XMedicaid
ND251S00000XMedicaid