Healthcare Provider Details

I. General information

NPI: 1427431220
Provider Name (Legal Business Name): NANCY LIN D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 DELMAR BLVD STE 201
UNIVERSITY CITY MO
63130-4334
US

IV. Provider business mailing address

2029 RUTGER ST # B
SAINT LOUIS MO
63104-2430
US

V. Phone/Fax

Practice location:
  • Phone: 314-721-5551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.032084
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2019014164
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN015189
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: