Healthcare Provider Details

I. General information

NPI: 1245244417
Provider Name (Legal Business Name): PETER C LIU D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19046 LA PUENTE RD
WEST COVINA CA
91792-2832
US

IV. Provider business mailing address

19888 SUNSET VISTA RD
WALNUT CA
91789-5328
US

V. Phone/Fax

Practice location:
  • Phone: 626-965-8310
  • Fax: 626-965-8321
Mailing address:
  • Phone: 909-595-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number37694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: