Healthcare Provider Details

I. General information

NPI: 1639187800
Provider Name (Legal Business Name): KRISTIAN LUNDGREN-KOSZEGHY DMD, MMSC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 MIDDLEFIELD RD STE 1
PALO ALTO CA
94301-2918
US

IV. Provider business mailing address

760 LA PLAYA ST
SAN FRANCISCO CA
94121-3262
US

V. Phone/Fax

Practice location:
  • Phone: 650-326-1400
  • Fax: 650-326-2909
Mailing address:
  • Phone: 415-221-5592
  • Fax: 415-221-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number51967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: