Healthcare Provider Details

I. General information

NPI: 1124432695
Provider Name (Legal Business Name): CHUNHUA CHILTON LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 STRATFORD AVE STE A
DIXON CA
95620-2001
US

IV. Provider business mailing address

5060 BRIMLEY WAY
SACRAMENTO CA
95835-1616
US

V. Phone/Fax

Practice location:
  • Phone: 707-678-3065
  • Fax: 707-678-3026
Mailing address:
  • Phone: 909-353-8291
  • Fax: 707-678-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number63496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: