Provider Demographics
NPI:1588810139
Name:FAXIO, LYNNE CAROL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:CAROL
Last Name:FAXIO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 CORPORATE LANE STE B11
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435
Mailing Address - Country:US
Mailing Address - Phone:757-934-6040
Mailing Address - Fax:757-934-6042
Practice Address - Street 1:2999 CORPORATE LANE STE B11
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3572
Practice Address - Country:US
Practice Address - Phone:757-934-6040
Practice Address - Fax:757-934-6042
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11240122300000X
VA0401412767122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist