Healthcare Provider Details

I. General information

NPI: 1477910602
Provider Name (Legal Business Name): ANTHONY LIEU DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 COMMERCE BLVD
ROHNERT PARK CA
94928-2421
US

IV. Provider business mailing address

6420 COMMERCE BLVD
ROHNERT PARK CA
94928-2421
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number55913
License Number StateCA

VIII. Authorized Official

Name: ANTHONY LIEU
Title or Position: OWNER
Credential: DMD
Phone: 707-795-4523