Healthcare Provider Details

I. General information

NPI: 1235149964
Provider Name (Legal Business Name): LOIS J. LUNDERMAN, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 VALPARAISO PKWY
VALPARAISO FL
32580-1203
US

IV. Provider business mailing address

395 VALPARAISO PKWY
VALPARAISO FL
32580-1203
US

V. Phone/Fax

Practice location:
  • Phone: 850-678-2012
  • Fax: 850-678-1453
Mailing address:
  • Phone: 850-678-2012
  • Fax: 850-678-1453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN13619
License Number StateFL

VIII. Authorized Official

Name: LOIS JOHNSON LUNDERMAN
Title or Position: DENTIST
Credential: D.D.S.
Phone: 850-678-2012