Healthcare Provider Details

I. General information

NPI: 1396859336
Provider Name (Legal Business Name): KELLY JAMES LUNDEEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 S 300 W
HURRICANE UT
84737-2198
US

IV. Provider business mailing address

75 S 300 W
HURRICANE UT
84737-2198
US

V. Phone/Fax

Practice location:
  • Phone: 435-635-5940
  • Fax: 435-635-5941
Mailing address:
  • Phone: 435-635-5940
  • Fax: 435-635-5941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1444449922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: