Provider Demographics
NPI:1316163678
Name:LUNDIN, LARRY C (DDS)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:LUNDIN
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 1:1741 MESQUITE AVE
Mailing Address - Street 2:B 100
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:928-855-0556
Mailing Address - Fax:928-855-2684
Practice Address - Street 1:1741 MESQUITE AVE
Practice Address - Street 2:B 100
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-855-0556
Practice Address - Fax:928-855-2684
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist