Healthcare Provider Details

I. General information

NPI: 1871336248
Provider Name (Legal Business Name): IVY LIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6059 BOYLSTON DR STE 150
SANDY SPRINGS GA
30328-4175
US

IV. Provider business mailing address

2651 SATELLITE BLVD APT 9012
DULUTH GA
30096-1168
US

V. Phone/Fax

Practice location:
  • Phone: 651-494-4167
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN29078
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124183
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: