Provider Demographics
NPI:1174650923
Name:LUNDGRIN, JERRY ROY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ROY
Last Name:LUNDGRIN
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:PO BOX 1424
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67402-1424
Mailing Address - Country:US
Mailing Address - Phone:785-825-5473
Mailing Address - Fax:785-825-8965
Practice Address - Street 1:909 E WAYNE AVE
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-2201
Practice Address - Country:US
Practice Address - Phone:785-825-5473
Practice Address - Fax:785-825-8965
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice