Provider Demographics
NPI:1134317712
Name:AMUNDSON, LISA KATHLEEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KATHLEEN
Last Name:AMUNDSON
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 1:6939 PINE ARBOR DR S
Mailing Address - Street 2:SUITE A104
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4580
Mailing Address - Country:US
Mailing Address - Phone:651-459-3514
Mailing Address - Fax:
Practice Address - Street 1:6939 PINE ARBOR DR S
Practice Address - Street 2:SUITE A104
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4580
Practice Address - Country:US
Practice Address - Phone:651-459-3514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND124601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice