=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760473839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT I-SUN LIN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2005
-----------------------------------------------------
Last Update Date | 06/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 75TH ST B1
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-969-6688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 RUMSEY PL
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-701-0702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019-026119
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------