Provider Demographics
NPI:1457771545
Name:LIN, DIANA (DMD, MPH)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:LIN
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 LAKESIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966
Mailing Address - Country:US
Mailing Address - Phone:215-938-7863
Mailing Address - Fax:215-941-7836
Practice Address - Street 1:2630 HOLME AVE STE 103
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3004
Practice Address - Country:US
Practice Address - Phone:215-938-7860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02849600204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty