Provider Demographics
NPI:1134269277
Name:LUNGREN, MARY JANE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARY JANE
Middle Name:
Last Name:LUNGREN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 CAMANO AVE
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:LANGLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98260-9577
Mailing Address - Country:US
Mailing Address - Phone:360-221-6373
Mailing Address - Fax:
Practice Address - Street 1:742 CAMANO AVE
Practice Address - Street 2:SUITE 101A
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260-9577
Practice Address - Country:US
Practice Address - Phone:360-221-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000063251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047121Medicaid