Healthcare Provider Details

I. General information

NPI: 1922196716
Provider Name (Legal Business Name): JOHN ROBERT LYTHGOE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 LAGUNA RD
FULLERTON CA
92835-2515
US

IV. Provider business mailing address

259 LAGUNA RD
FULLERTON CA
92835-2515
US

V. Phone/Fax

Practice location:
  • Phone: 714-739-6651
  • Fax: 714-738-6653
Mailing address:
  • Phone: 714-739-6651
  • Fax: 714-738-6653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number25586
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: