Healthcare Provider Details

I. General information

NPI: 1417169830
Provider Name (Legal Business Name): JESAN LIU D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 FREEPORT BLVD STE 4
SACRAMENTO CA
95822-3517
US

IV. Provider business mailing address

5665 FREEPORT BLVD STE 4
SACRAMENTO CA
95822-3517
US

V. Phone/Fax

Practice location:
  • Phone: 916-421-4790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: