Provider Demographics
NPI:1023217395
Name:LYNN, AGATHA JERRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:AGATHA
Middle Name:JERRY
Last Name:LYNN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:811 SAINT ANDREWS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7187
Mailing Address - Country:US
Mailing Address - Phone:843-571-7951
Mailing Address - Fax:843-571-7952
Practice Address - Street 1:811 ST ANDREWS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-571-7951
Practice Address - Fax:843-571-7952
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4332122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist