Provider Demographics
NPI:1245367077
Name:LUNDGRIN DENTAL ASSOCIATION CHTD.
Entity type:Organization
Organization Name:LUNDGRIN DENTAL ASSOCIATION CHTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUNDGRIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-825-5473
Mailing Address - Street 1:PO BOX 1424
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67402-1424
Mailing Address - Country:US
Mailing Address - Phone:785-825-5473
Mailing Address - Fax:785-825-8965
Practice Address - Street 1:909 E WAYNE AVE
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-2201
Practice Address - Country:US
Practice Address - Phone:785-825-5473
Practice Address - Fax:785-825-8965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS69291223G0001X
KS46961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty