Healthcare Provider Details

I. General information

NPI: 1962612622
Provider Name (Legal Business Name): ANTHONY K LIEU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6230 STATE FARM DR.
ROHNERT PARK CA
94928
US

IV. Provider business mailing address

6230 STATE FARM DR.
ROHNERT PARK CA
94928
US

V. Phone/Fax

Practice location:
  • Phone: 707-795-4523
  • Fax: 707-586-1650
Mailing address:
  • Phone: 707-795-4523
  • Fax: 707-586-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number55913
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number018001594
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: