Healthcare Provider Details

I. General information

NPI: 1699981480
Provider Name (Legal Business Name): TORD MIKAEL LUNDGREN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD D4-4
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100405
GAINESVILLE FL
32610-0405
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5800
  • Fax: 352-392-3070
Mailing address:
  • Phone: 352-392-4305
  • Fax: 352-392-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberSP 241
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: