Provider Demographics
NPI:1588052377
Name:LUNDELL, JODY MILBERT (GDH)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:MILBERT
Last Name:LUNDELL
Suffix:
Gender:F
Credentials:GDH
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:ELLEN
Other - Last Name:MILBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:GDH
Mailing Address - Street 1:3664 MOUNT VERNON LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-9382
Mailing Address - Country:US
Mailing Address - Phone:414-303-2550
Mailing Address - Fax:
Practice Address - Street 1:3664 MOUNT VERNON LN
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-9382
Practice Address - Country:US
Practice Address - Phone:414-303-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5739-16124Q00000X
MNH2738124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist