Provider Demographics
NPI:1205906617
Name:LUNDBERG, QUINN L JR (DMD)
Entity type:Individual
Prefix:MR
First Name:QUINN
Middle Name:L
Last Name:LUNDBERG
Suffix:JR
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 1:409 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15824
Mailing Address - Country:US
Mailing Address - Phone:814-268-6614
Mailing Address - Fax:814-268-6614
Practice Address - Street 1:409 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:PA
Practice Address - Zip Code:15824
Practice Address - Country:US
Practice Address - Phone:814-268-6614
Practice Address - Fax:814-268-6614
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027644L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000675116OtherUNITED CONCORDIA
PA000675116OtherUNITED CONCORDIA