Healthcare Provider Details

I. General information

NPI: 1124717954
Provider Name (Legal Business Name): JIAWEI LIU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S STATE COLLEGE BLVD UNIT 362
BREA CA
92821-1614
US

IV. Provider business mailing address

115 S STATE COLLEGE BLVD UNIT 362
BREA CA
92821-1614
US

V. Phone/Fax

Practice location:
  • Phone: 408-666-6276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS111603
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: