Provider Demographics
NPI:1982136289
Name:LIN, IVY FANGYU (DMD)
Entity type:Individual
Prefix:DR
First Name:IVY
Middle Name:FANGYU
Last Name:LIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:FANG YU
Other - Middle Name:
Other - Last Name:LIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 12TH AVE S STE 901
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2712
Mailing Address - Country:US
Mailing Address - Phone:206-548-3058
Mailing Address - Fax:206-262-0859
Practice Address - Street 1:1200 12TH AVE S STE 401
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2730
Practice Address - Country:US
Practice Address - Phone:206-548-5850
Practice Address - Fax:206-328-4034
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2022-06-20
Deactivation Date:2017-10-30
Deactivation Code:
Reactivation Date:2017-11-13
Provider Licenses
StateLicense IDTaxonomies
WADE60857215122300000X
WADR60757597390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist