Provider Demographics
NPI:1760473839
Name:LIN, VINCENT I-SUN (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:I-SUN
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 1:133 RUMSEY PL
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2650
Mailing Address - Country:US
Mailing Address - Phone:630-701-0702
Mailing Address - Fax:
Practice Address - Street 1:1400 75TH ST
Practice Address - Street 2:B1
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516
Practice Address - Country:US
Practice Address - Phone:630-969-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0261191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1005609Medicaid