Healthcare Provider Details

I. General information

NPI: 1962872887
Provider Name (Legal Business Name): BRENT C LIN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39236 ARGONAUT WAY
FREMONT CA
94538-1306
US

IV. Provider business mailing address

PO BOX 1137
SAN RAMON CA
94583-1137
US

V. Phone/Fax

Practice location:
  • Phone: 510-739-0701
  • Fax: 510-739-0007
Mailing address:
  • Phone: 925-577-8779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: BRENT LIN
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 925-577-8779