Healthcare Provider Details

I. General information

NPI: 1467971119
Provider Name (Legal Business Name): RICHARD FLYNN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 OHIO ST
GREAT LAKES IL
60088-3155
US

IV. Provider business mailing address

42 FARMSIDE DR
PEMBROKE MA
02359-1727
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number33479
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: