Healthcare Provider Details

I. General information

NPI: 1124127956
Provider Name (Legal Business Name): JOHNNY S LIU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7168 ARCHIBALD AVE SUITE 200
ALTA LOMA CA
91701
US

IV. Provider business mailing address

7168 ARCHIBALD AVE SUITE 200
ALTA LOMA CA
91701
US

V. Phone/Fax

Practice location:
  • Phone: 909-944-3120
  • Fax: 909-483-3957
Mailing address:
  • Phone: 909-944-3120
  • Fax: 909-483-3957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number51966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: