Provider Demographics
NPI:1194802918
Name:LUNDGREN, JACK (DDS)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:JACKMAN
Other - Last Name:LUNDGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:4347 RICE ST
Mailing Address - Street 2:STE 201
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-1335
Mailing Address - Country:US
Mailing Address - Phone:808-246-4881
Mailing Address - Fax:
Practice Address - Street 1:4347 RICE ST
Practice Address - Street 2:STE 201
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1335
Practice Address - Country:US
Practice Address - Phone:808-246-4881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHI898122300000X
CA20227122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist