Healthcare Provider Details

I. General information

NPI: 1063597300
Provider Name (Legal Business Name): JULIA MARY GUDMUNDSEN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 W ST JOE HWY
LANSING MI
48917-4023
US

IV. Provider business mailing address

5001 W ST JOE HWY
LANSING MI
48917-4023
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-2358
  • Fax: 517-321-4420
Mailing address:
  • Phone: 517-321-2358
  • Fax: 517-321-4420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901015606
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: