Provider Demographics
NPI:1609568658
Name:LUNDGREN, ALLISON AUDREY (DMD)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:AUDREY
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:VERDI
Mailing Address - State:NV
Mailing Address - Zip Code:89439-1039
Mailing Address - Country:US
Mailing Address - Phone:775-750-2080
Mailing Address - Fax:
Practice Address - Street 1:2855 35TH AVE UNIT B
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-9474
Practice Address - Country:US
Practice Address - Phone:970-660-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.002060841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program