Healthcare Provider Details

I. General information

NPI: 1144341454
Provider Name (Legal Business Name): DR. CHANGRUI LIU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 KANAN RD
AGOURA HILLS CA
91301-3358
US

IV. Provider business mailing address

3110 GLENDON AVE
LOS ANGELES CA
90034-3404
US

V. Phone/Fax

Practice location:
  • Phone: 818-991-8881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number41944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: