Provider Demographics
NPI:1477621548
Name:TUNG, SU HSIN LIAO
Entity Type:Individual
Prefix:
First Name:SU HSIN
Middle Name:LIAO
Last Name:TUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:503 CEDAR ST
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772
Mailing Address - Country:US
Mailing Address - Phone:563-886-3223
Mailing Address - Fax:
Practice Address - Street 1:503 CEDAR ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IA
Practice Address - Zip Code:52772-1738
Practice Address - Country:US
Practice Address - Phone:563-886-3233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0140582Medicaid