Provider Demographics
NPI:1053056580
Name:LYNCH, JACQUELINE NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:LYNCH
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 1:3665 BEE RIDGE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-1058
Mailing Address - Country:US
Mailing Address - Phone:941-953-4288
Mailing Address - Fax:
Practice Address - Street 1:3665 BEE RIDGE RD STE 108
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1058
Practice Address - Country:US
Practice Address - Phone:941-953-4288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN271191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program