Healthcare Provider Details

I. General information

NPI: 1699737833
Provider Name (Legal Business Name): RICHARD E LYNNE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4431 68TH ST US ARMY DENTAL ACTIVITY
FORT HOOD TX
76544
US

IV. Provider business mailing address

4431 68TH ST US ARMY DENTAL ACTIVITY
FORT HOOD TX
76544
US

V. Phone/Fax

Practice location:
  • Phone: 254-287-2705
  • Fax: 254-287-1786
Mailing address:
  • Phone: 254-287-2705
  • Fax: 254-287-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE7421
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4132
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: