Provider Demographics
NPI:1457342156
Name:LYNN, JOHN WORTH (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WORTH
Last Name:LYNN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2750
Mailing Address - Country:US
Mailing Address - Phone:804-732-0056
Mailing Address - Fax:804-732-1420
Practice Address - Street 1:104 MORTON AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2750
Practice Address - Country:US
Practice Address - Phone:804-732-0056
Practice Address - Fax:804-732-1420
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7805675Medicaid