Provider Demographics
NPI:1588779086
Name:JETT, LYNN THORNTON (DDS)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:THORNTON
Last Name:JETT
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 1:3116 TYRE NECK RD.
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703
Mailing Address - Country:US
Mailing Address - Phone:757-483-2110
Mailing Address - Fax:757-686-0679
Practice Address - Street 1:3116 TYRE NECK RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703
Practice Address - Country:US
Practice Address - Phone:757-483-2110
Practice Address - Fax:757-686-0679
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010063211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010143039Medicaid
VA091586OtherANTHEM PROVIDER NUMBER
VA008000883Medicaid
VA010143039Medicaid
VAU44582Medicare UPIN