Healthcare Provider Details

I. General information

NPI: 1730697723
Provider Name (Legal Business Name): SHASAN WILLIAM LIOU, DMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12331 SW 3RD ST STE 5
PLANTATION FL
33325-2813
US

IV. Provider business mailing address

10021 PINES BLVD STE 100
PEMBROKE PINES FL
33024-6191
US

V. Phone/Fax

Practice location:
  • Phone: 844-304-5437
  • Fax:
Mailing address:
  • Phone: 844-304-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN19743
License Number StateFL

VIII. Authorized Official

Name: DR. SHASAN WILLIAM LIOU
Title or Position: MANAGER
Credential: DMD
Phone: 678-427-1412