Provider Demographics
NPI:1477153526
Name:BRIAN LYNGAAS, DDS, PLLC
Entity Type:Organization
Organization Name:BRIAN LYNGAAS, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:131-377-2539
Mailing Address - Street 1:18518 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3232
Mailing Address - Country:US
Mailing Address - Phone:248-473-0050
Mailing Address - Fax:248-473-7490
Practice Address - Street 1:18518 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3232
Practice Address - Country:US
Practice Address - Phone:248-473-0050
Practice Address - Fax:248-473-7490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1275545626Medicaid