=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255945945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK LIN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2020
-----------------------------------------------------
Last Update Date | 09/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10750 QUEENS BLVD STE 2
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-4266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-793-1777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1086 IRIS PL
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-724-3537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 061160
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------