MEDICARE: LARRY C LUNDIN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3730	AZ

General Provider Information

NPI Number	:	1316163678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY C LUNDIN DDS

Provider Business Mailing Address
First Line	:	1741 MESQUITE AVE
Second Line	:	B 100
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403
Country	:	US
Telephone Number	:	928-855-0556
Fax Number	:	928-855-2684

Provider Business Practice Location Address
First Line	:	1741 MESQUITE AVE
Second Line	:	B 100
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403
Country	:	US
Telephone Number	:	928-855-0556
Fax Number	:	928-855-2684

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	03/09/2015

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