Healthcare Provider Details

I. General information

NPI: 1063720852
Provider Name (Legal Business Name): LYNETTE LEANOR LLINAS R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11307 SW OLMSTEAD DR
PORT SAINT LUCIE FL
34987-1947
US

IV. Provider business mailing address

11307 SW OLMSTEAD DR
PORT SAINT LUCIE FL
34987-1947
US

V. Phone/Fax

Practice location:
  • Phone: 772-345-0577
  • Fax:
Mailing address:
  • Phone: 772-345-0577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDEH 18811
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: