=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770924888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIN DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2013
-----------------------------------------------------
Last Update Date | 09/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4120 ROSEMEAD BLVD
-----------------------------------------------------
City | ROSEMEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91770-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-286-7800
-----------------------------------------------------
Fax | 626-286-7600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4120 ROSEMEAD BLVD
-----------------------------------------------------
City | ROSEMEAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91770-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-286-7800
-----------------------------------------------------
Fax | 626-286-7600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CHUN NAN LIN
-----------------------------------------------------
Credential | D.D.S., M.S.
-----------------------------------------------------
Telephone | 626-286-7800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 54515
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------