Provider Demographics
NPI:1619152717
Name:LUNDQUIST, DANIEL J (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:LUNDQUIST
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 1:2701 NE 114TH AVE STE K-6
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4289
Mailing Address - Country:US
Mailing Address - Phone:360-892-7107
Mailing Address - Fax:360-891-8361
Practice Address - Street 1:2701 NE 114TH AVE STE K-6
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4289
Practice Address - Country:US
Practice Address - Phone:360-892-7107
Practice Address - Fax:360-891-8361
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007609122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5026760Medicaid