Provider Demographics
NPI:1134345408
Name:LUNDSTROM, GEORGE ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROBERT
Last Name:LUNDSTROM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 NORTH 9TH AVE.
Mailing Address - Street 2:P.O. BOX 690
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-0690
Mailing Address - Country:US
Mailing Address - Phone:507-377-1659
Mailing Address - Fax:
Practice Address - Street 1:209 NORTH 9TH AVE.
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-0690
Practice Address - Country:US
Practice Address - Phone:507-377-1659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice