Provider Demographics
NPI:1902301021
Name:LIN, KYLE SHIH-KAE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:SHIH-KAE
Last Name:LIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15902 EL CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2162
Mailing Address - Country:US
Mailing Address - Phone:858-442-1737
Mailing Address - Fax:
Practice Address - Street 1:9870 HIBERT ST STE D12
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1091
Practice Address - Country:US
Practice Address - Phone:858-566-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1043361223G0001X
390200000X
HICSDT-1091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program