Healthcare Provider Details

I. General information

NPI: 1306090345
Provider Name (Legal Business Name): PETER A LJUNGBERGH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PETER LINDSTROM

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36101 BOB HOPE DR. SUITE B-4
RANCHO MIRAGE CA
92270
US

IV. Provider business mailing address

36101 BOB HOPE DR. SUITE B-4
RANCHO MIRAGE CA
92270
US

V. Phone/Fax

Practice location:
  • Phone: 760-321-4095
  • Fax: 760-321-4095
Mailing address:
  • Phone: 760-321-4095
  • Fax: 760-321-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number35045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: