Basic Information
Provider Information | |||||||||
NPI: | 1982136289 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIN | ||||||||
FirstName: | IVY | ||||||||
MiddleName: | FANGYU | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIN | ||||||||
OtherFirstName: | FANG YU | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1200 12TH AVE S STE 901 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981442712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065483058 | ||||||||
FaxNumber: | 2062620859 | ||||||||
Practice Location | |||||||||
Address1: | 1200 12TH AVE S STE 401 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981442730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065485850 | ||||||||
FaxNumber: | 2063284034 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2017 | ||||||||
LastUpdateDate: | 06/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 10/30/2017 | ||||||||
NPIReactivationDate: | 11/13/2017 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60857215 | WA | Y |   | Dental Providers | Dentist |   |
No ID Information.