Provider Demographics
NPI:1750631297
Name:LIN, CONNIE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:
Last Name:LIN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MISS
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2950 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2228
Mailing Address - Country:US
Mailing Address - Phone:510-535-4450
Mailing Address - Fax:510-535-4494
Practice Address - Street 1:2950 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2228
Practice Address - Country:US
Practice Address - Phone:510-535-4450
Practice Address - Fax:510-535-4494
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12120124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist