Healthcare Provider Details

I. General information

NPI: 1629036298
Provider Name (Legal Business Name): JIGUO LIU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N PALAFOX ST
PENSACOLA FL
32501-1723
US

IV. Provider business mailing address

2200 N PALAFOX ST
PENSACOLA FL
32501-1723
US

V. Phone/Fax

Practice location:
  • Phone: 850-436-4630
  • Fax: 850-436-2095
Mailing address:
  • Phone: 850-436-4630
  • Fax: 850-436-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16771
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: