Provider Demographics
NPI:1093893471
Name:ADDIEGO, LYNNE JULIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:JULIA
Last Name:ADDIEGO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NELSON ST
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-3312
Mailing Address - Country:US
Mailing Address - Phone:802-479-1185
Mailing Address - Fax:
Practice Address - Street 1:161 US ROUTE 302 - BERLIN
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641
Practice Address - Country:US
Practice Address - Phone:802-476-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-0001234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006036Medicaid