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General NPI Number Information
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NPI Number | 1093767345
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Entity Type | Individual
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Provider Name | WALLACE EARL LUNDEN III DDS
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Gender | Male
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Dates
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Enumeration Date | 05/16/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1404 EAST 66TH STREET
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City | RICHFIELD
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State | MN
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Zip | 55423
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Country | US
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Telephone | 612-866-9622
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Fax | 612-866-3877
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Provider Business Mailing Address
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Address Line | 3901 AUBURN DRIVE
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City | MINNETONKA
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State | MN
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Zip | 55305
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Country | US
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Telephone | 952-938-8110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8483
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License Number State | MN
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