Healthcare Provider Details

I. General information

NPI: 1942666284
Provider Name (Legal Business Name): LIWEN TAO D.D.S., M.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 12/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2753 STATE ROAD 580 STE 108
CLEARWATER FL
33761-3351
US

IV. Provider business mailing address

2753 STATE ROAD 580 STE 108
CLEARWATER FL
33761-3351
US

V. Phone/Fax

Practice location:
  • Phone: 727-799-6995
  • Fax:
Mailing address:
  • Phone: 727-799-6995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN0012253
License Number StateFL

VIII. Authorized Official

Name: LIWEN TAO
Title or Position: DR
Credential: DDS
Phone: 727-799-6995