Healthcare Provider Details

I. General information

NPI: 1588852479
Provider Name (Legal Business Name): YIWEN LIU, DDS, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11103 VENICE BLVD
LOS ANGELES CA
90034-6914
US

IV. Provider business mailing address

2121 BELOIT AVE APT 304
LOS ANGELES CA
90025-6263
US

V. Phone/Fax

Practice location:
  • Phone: 310-559-9191
  • Fax: 310-559-9797
Mailing address:
  • Phone: 310-486-9989
  • Fax: 310-478-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number46875
License Number StateCA

VIII. Authorized Official

Name: DR. YIWEN LIU
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 310-559-9191