Healthcare Provider Details

I. General information

NPI: 1689882425
Provider Name (Legal Business Name): KWANG-TA LIU D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 SCOTT BLVD STE C1
SANTA CLARA CA
95050-4547
US

IV. Provider business mailing address

1150 SCOTT BLVD STE C1
SANTA CLARA CA
95050-4547
US

V. Phone/Fax

Practice location:
  • Phone: 408-554-1655
  • Fax: 408-554-1659
Mailing address:
  • Phone: 408-554-1655
  • Fax: 408-554-1659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number29623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: