Provider Demographics
NPI:1053793893
Name:LIN, FREDERICK (DMD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
Last Name:LIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 E LONE CACTUS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-6888
Mailing Address - Country:US
Mailing Address - Phone:925-262-3069
Mailing Address - Fax:
Practice Address - Street 1:4022 E GREENWAY RD STE 12
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4799
Practice Address - Country:US
Practice Address - Phone:602-457-4788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-28
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0092451223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice