Provider Demographics
NPI:1528824117
Name:SUK, MICHAEL IAN (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:IAN
Last Name:SUK
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 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-261-7848
Mailing Address - Fax:360-232-8400
Practice Address - Street 1:1057 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2509
Practice Address - Country:US
Practice Address - Phone:360-414-1300
Practice Address - Fax:360-636-4420
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE615605221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice