Provider Demographics
NPI:1548349954
Name:GRIEBAHN, LYNN RAYMOND JR (DDS)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:RAYMOND
Last Name:GRIEBAHN
Suffix:JR
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 1:1905 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2908
Mailing Address - Country:US
Mailing Address - Phone:563-323-2571
Mailing Address - Fax:563-323-1069
Practice Address - Street 1:1905 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2908
Practice Address - Country:US
Practice Address - Phone:563-323-2571
Practice Address - Fax:563-323-1069
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA69431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0431924Medicaid