Provider Demographics
NPI:1679603161
Name:LINDGREN, LARS GUSTAV (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:GUSTAV
Last Name:LINDGREN
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 1:1205 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-1203
Mailing Address - Country:US
Mailing Address - Phone:805-528-1695
Mailing Address - Fax:805-528-1697
Practice Address - Street 1:1205 4TH ST
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-1203
Practice Address - Country:US
Practice Address - Phone:805-528-1695
Practice Address - Fax:805-528-1697
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46873122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist