Provider Demographics
NPI:1003026337
Name:LUNDSTROM, JAMES FRED
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:FRED
Last Name:LUNDSTROM
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 1:4110 40TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-293-7718
Mailing Address - Fax:701-293-1296
Practice Address - Street 1:4110 40TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:701-293-7718
Practice Address - Fax:701-293-1296
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND1380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist