Healthcare Provider Details

I. General information

NPI: 1164862348
Provider Name (Legal Business Name): JUNGYI ALEXIS LIU DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUNG-YI LIU JUNGYI , DDS

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRINCE HALL ROOM 3301 11092 ANDERSON STREET
LOMA LINDA CA
92350-0001
US

IV. Provider business mailing address

7353 ELLENA W
RANCHO CUCAMONGA CA
91730-8356
US

V. Phone/Fax

Practice location:
  • Phone: 905-588-4690
  • Fax:
Mailing address:
  • Phone: 210-596-2506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number108565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: