Healthcare Provider Details

I. General information

NPI: 1063401545
Provider Name (Legal Business Name): LYNN WILLIAM MARR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2534 UNIVERSITY DR S SUITE 3
FARGO ND
58103-5700
US

IV. Provider business mailing address

2534 UNIVERSITY DR S SUITE 3
FARGO ND
58103-5700
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-0761
  • Fax: 701-293-6158
Mailing address:
  • Phone: 701-293-0761
  • Fax: 701-293-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1481
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: