Basic Information
| Provider Information | |||||||||
| NPI: | 1235651795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYNOTT | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | MORIE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4697334391 | ||||||||
| FaxNumber: | 8177022140 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 STALCUP RD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761191726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177021100 | ||||||||
| FaxNumber: | 8179200729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2017 | ||||||||
| LastUpdateDate: | 12/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 33036 | TX | N | Dental Providers | Dentist | 1223G0001X | 33036 | TX | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 33036 | 01 | TX | STATE BOARD OF DENTAL EXAMINERS | OTHER |