Provider Demographics
NPI:1043359177
Name:LUNDBERG, BRENT DEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DEE
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-7124
Mailing Address - Country:US
Mailing Address - Phone:801-255-4953
Mailing Address - Fax:
Practice Address - Street 1:684 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7124
Practice Address - Country:US
Practice Address - Phone:801-255-4953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1382061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice