Healthcare Provider Details

I. General information

NPI: 1033291687
Provider Name (Legal Business Name): BRETT B LUND DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 MARTIN ST STE B
TWIN FALLS ID
83301-4563
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-7447
  • Fax: 208-733-5940
Mailing address:
  • Phone: 208-734-3312
  • Fax: 208-734-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4191
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: