Provider Demographics
NPI:1497259162
Name:LYN, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:LYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 REVELL CIR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-1389
Mailing Address - Country:US
Mailing Address - Phone:909-800-2480
Mailing Address - Fax:
Practice Address - Street 1:30 REVELL CIR
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-1389
Practice Address - Country:US
Practice Address - Phone:909-800-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18603124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist