Provider Demographics
NPI:1629284039
Name:LUNDBERG, BRIAN LEE (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
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 1:655 DARWIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6156
Mailing Address - Country:US
Mailing Address - Phone:435-752-7442
Mailing Address - Fax:435-752-4929
Practice Address - Street 1:655 DARWIN AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6156
Practice Address - Country:US
Practice Address - Phone:435-752-7442
Practice Address - Fax:435-752-4929
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138906-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice