Provider Demographics
NPI:1427431220
Name:LIN, NANCY (DMD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:LIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 RUTGER ST # B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7171 DELMAR BLVD STE 201
Practice Address - Street 2:
Practice Address - City:UNIVERSITY CITY
Practice Address - State:MO
Practice Address - Zip Code:63130-4334
Practice Address - Country:US
Practice Address - Phone:314-721-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032084122300000X
MO20190141641223X0400X
GADN015189122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist