Provider Demographics
NPI:1396202321
Name:LIN, KEVIN CHANG (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHANG
Last Name:LIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E 30TH ST APT 10A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8298
Mailing Address - Country:US
Mailing Address - Phone:808-381-1009
Mailing Address - Fax:
Practice Address - Street 1:13107 40TH RD STE E36
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5205
Practice Address - Country:US
Practice Address - Phone:718-888-1817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty