=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649369000
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNN J. ALBRECHT D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21767 OMEGA CT
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46528-7809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-875-1717
-----------------------------------------------------
Fax | 574-875-9717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23285 US HIGHWAY 12
-----------------------------------------------------
City | EDWARDSBURG
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49112-9223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-699-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 12009103A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------