Healthcare Provider Details

I. General information

NPI: 1881754679
Provider Name (Legal Business Name): GARY LUNSTAD D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 VILLAGE CENTER DR #140
NORTH OAKS MN
55127-3019
US

IV. Provider business mailing address

700 VILLAGE CENTER DR #140
NORTH OAKS MN
55127-3019
US

V. Phone/Fax

Practice location:
  • Phone: 651-490-3155
  • Fax: 651-490-1280
Mailing address:
  • Phone: 651-490-3155
  • Fax: 651-490-1280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7109
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: