Basic Information
| Provider Information | |||||||||
| NPI: | 1770788408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | LYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 N COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748202847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214570 | ||||||||
| FaxNumber: | 5804214595 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 N COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748202847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214570 | ||||||||
| FaxNumber: | 5804214595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5209 | OK | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1305209 | 05 | OK | MEDICAID |