Provider Demographics
NPI:1265668974
Name:LYNN, TRACE LANIER (DDS)
Entity Type:Individual
Prefix:
First Name:TRACE
Middle Name:LANIER
Last Name:LYNN
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 1:3107 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-6201
Mailing Address - Country:US
Mailing Address - Phone:337-625-9911
Mailing Address - Fax:337-625-9912
Practice Address - Street 1:3107 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-6201
Practice Address - Country:US
Practice Address - Phone:337-625-9911
Practice Address - Fax:337-625-9912
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA5970122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist