Provider Demographics
NPI:1144622655
Name:JULIA M GUDMUNDSEN PC
Entity type:Organization
Organization Name:JULIA M GUDMUNDSEN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:GUDMUNDSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:517-321-2358
Mailing Address - Street 1:5001 W ST JOE HWY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4023
Mailing Address - Country:US
Mailing Address - Phone:517-321-2358
Mailing Address - Fax:517-321-4420
Practice Address - Street 1:5001 W ST JOE HWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4023
Practice Address - Country:US
Practice Address - Phone:517-321-2358
Practice Address - Fax:517-321-4420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI156061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063597300OtherNPPES