Provider Demographics
NPI:1639286305
Name:LYONS, JOHN ANTHONY (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:LYONS
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 1:2041 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5147
Mailing Address - Country:US
Mailing Address - Phone:336-777-0303
Mailing Address - Fax:336-777-3448
Practice Address - Street 1:3053 FREEDOM DR STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-3862
Practice Address - Country:US
Practice Address - Phone:704-393-3911
Practice Address - Fax:704-392-1096
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC74571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
902E3OtherBLUE CROSS BLUE SHIELD NC
NC89-902E3Medicaid