Provider Demographics
NPI:1558417253
Name:PEACE, MARLIN DWAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARLIN
Middle Name:DWAYNE
Last Name:PEACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4225
Mailing Address - Country:US
Mailing Address - Phone:903-592-1992
Mailing Address - Fax:903-592-6401
Practice Address - Street 1:300 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4225
Practice Address - Country:US
Practice Address - Phone:903-592-1992
Practice Address - Fax:903-592-6401
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX142321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice