Healthcare Provider Details

I. General information

NPI: 1326011065
Provider Name (Legal Business Name): JOHN ROBERT LUNDSTROM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57337 YUCCA TRL
YUCCA VALLEY CA
92284-3851
US

IV. Provider business mailing address

57945 CARLYLE DR
YUCCA VALLEY CA
92284-6210
US

V. Phone/Fax

Practice location:
  • Phone: 760-365-7691
  • Fax:
Mailing address:
  • Phone: 319-594-6132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number58731
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7627
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: