Healthcare Provider Details

I. General information

NPI: 1902989262
Provider Name (Legal Business Name): PETER C. LIU D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18710 AMAR RD STE D
WALNUT CA
91789-4571
US

IV. Provider business mailing address

18710 AMAR RD STE D
WALNUT CA
91789-4571
US

V. Phone/Fax

Practice location:
  • Phone: 909-598-2999
  • Fax: 626-965-9955
Mailing address:
  • Phone: 909-598-2999
  • Fax: 626-965-9955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number35917
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number49934
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number38226
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number24358
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number41855
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number53896
License Number StateCA

VIII. Authorized Official

Name: NONI CABRAL
Title or Position: FRONT OFFICE
Credential:
Phone: 909-598-2999