Provider Demographics
NPI:1144538596
Name:LORENZO, MARY LEAH TAN (DDS)
Entity type:Individual
Prefix:
First Name:MARY LEAH
Middle Name:TAN
Last Name:LORENZO
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 1:7540 CANBY AVE
Mailing Address - Street 2:#2
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-8206
Mailing Address - Country:US
Mailing Address - Phone:818-645-7375
Mailing Address - Fax:
Practice Address - Street 1:9535 RESEDA BLVD
Practice Address - Street 2:STE 213
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-2310
Practice Address - Country:US
Practice Address - Phone:818-718-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA588681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice