Provider Demographics
NPI:1689687584
Name:SUNDELL, TACY MARIE (DDS)
Entity type:Individual
Prefix:
First Name:TACY
Middle Name:MARIE
Last Name:SUNDELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11300 CANTRELL RD STE 303
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-1844
Mailing Address - Country:US
Mailing Address - Phone:501-228-5700
Mailing Address - Fax:
Practice Address - Street 1:11300 CANTRELL RD STE 303
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-1844
Practice Address - Country:US
Practice Address - Phone:501-228-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR33521223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1493112OtherUNITED CONCORDIA
AR5X406OtherBLUE CROSS PROVIDER NUMBE
AR421591182OtherTAX ID NUMBER