Provider Demographics
NPI:1952762718
Name:LUNDSTROM, NICANDRA
Entity type:Individual
Prefix:
First Name:NICANDRA
Middle Name:
Last Name:LUNDSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SYCAMORE AVE APT 537
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6721
Mailing Address - Country:US
Mailing Address - Phone:864-353-1673
Mailing Address - Fax:
Practice Address - Street 1:86 MDG
Practice Address - Street 2:UNIT 3215
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094
Practice Address - Country:US
Practice Address - Phone:314-479-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice