Provider Demographics
NPI:1275521072
Name:LIN, MARIAN TZU MIAO (DDS)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:TZU MIAO
Last Name:LIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8312 E. TRUCKEE WAY
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808
Mailing Address - Country:US
Mailing Address - Phone:425-214-3670
Mailing Address - Fax:
Practice Address - Street 1:1205 W. RENAISSANCE PKWY
Practice Address - Street 2:UNIT 240
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376
Practice Address - Country:US
Practice Address - Phone:909-746-5000
Practice Address - Fax:310-820-0408
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000098121223G0001X
CADDS1058141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049036Medicaid
WA9812OtherWASHINGTON DENTAL SERVICE