Provider Demographics
NPI:1831124239
Name:LUNDTVEDT, GAYLE Y (DMD)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:Y
Last Name:LUNDTVEDT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1993 FRONTAGE RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4633
Mailing Address - Country:US
Mailing Address - Phone:520-458-4646
Mailing Address - Fax:520-803-0626
Practice Address - Street 1:1993 FRONTAGE RD
Practice Address - Street 2:SUITE 208
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4633
Practice Address - Country:US
Practice Address - Phone:520-458-4646
Practice Address - Fax:520-803-0626
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice