Healthcare Provider Details

I. General information

NPI: 1194482711
Provider Name (Legal Business Name): ANDY LIU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20700 AVALON BLVD # 600
CARSON CA
90746-3701
US

IV. Provider business mailing address

3110 GLENDON AVE
LOS ANGELES CA
90034-3404
US

V. Phone/Fax

Practice location:
  • Phone: 844-303-4560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number104715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: